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Signature of I.iccuf,c-c/i.)-crottc. CV)("' ''t ''
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SECTION 8 :CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: S "it? StRigh A4(` N ■••101111s, 0 C. at-{C,
License Number
Address O`d iZ Expiration Date
/
Signature Telephone
,:w�, .. _ ,, . ,r3P , .� "n, �. Not Applicable ❑
�R� e• E �m=� v men <. •n r.,c_.r���-�.� �._�, ..��� �,�, h
" c-\ w Qv i\ \\ \ a
Company Name Registration Number
3 c.42>l I
Address
Expiration Date
Telephone CSZ G- c(-1G
SECTION 10-WORKERS',COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of e building permit.
Signed Affidavit Attached Yes No ❑
1gl. - H ome° wne ]ox mutton
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside, on which there
is,or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
;also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
4144.
SECTION=DES(RIPTIONtOF PROPOSED WORK check alI a••licable
� ,...
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition" New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ' Q..vn■ v E. QV.St ,K' Va. k .0 ft Tom\ to , 4 . . w C444N
Alteration of existing bedroom Yes C No Adding new bedroom Yes / No
Attached Narrative l -' Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet 0
0,131f :MM s a "d of ard'dition>to exi`stiirk;ticTtit ti c iliVI te' ttt e fotr W:i g:
a. Use of building : One Family Two Family Other ✓
3—s
b. Number of rooms in each family unit: V14,-\ Number of Bathrooms
c. Is there a garage attached? (O
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes_ _No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject property
hereby authorize _to act on
my behalf, in al matter relative t work authorized by this building permit application.
Signatu e of caner Date
I, S W��V 10-+4+4`., QQfi=5 or\tb.w %■13\Dlk-C S , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
of/6/.
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
•
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW . YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook;' body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IFYES, describe size, type and location:
•
. •
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Ci�vT�fNnrtharnpton
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�� Aul|dUnQDepar�rneni
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_ _ - -'- ' 212 Main Street :....,,,*,,,:z...„ti:,.,.,, ,i,; zijoptg :f:;-,,)7;r;--:::;7 -,:,,,..,:::jr'.:„.„..,4,:p..,...;*:,...,,,,,,::
R0onnlOO
O "DR�m '
-�� , , �"~.nrthon?pton' ��AOlObD
phone 413-
Fax
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�PPUCAT0N��OCONSTRoCT. ALT�R, REPA0. RENOVATE 0R DEMOLISH A ONE ORTVY0FA01|LYDYYELL\NG
This SECTION ' 3!TE |NFOR MA|nOm 3
^m,a,1.1 Pro pert Address:
_.�S-4 _--
' oo�����k wK°
Elm St. District
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SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
---_�_
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9�� ��� ~_=� «1� .Owner of 2.1
_5. *„ � .: ^2,..c � % w ~~ , mno xouess ��
~,a,
mn, ` ~| w
2.2Avthoriz�d�yg�0:
! ��«~ ~°�� -�� k
/ C '��� WnUin3 Address:
�� ���Name(Plint) ...004t4j.
Signature -I
SECTION
8_-_E SI M8_�IE D CONS TREUs�CTm(0a�tN e�d C�CO yoSsT�5(
Dollars) to ic Item
/ �
�)ic i
a( Use Only
/ c2mp(ete'd bpermhanp|ican\ _ (a)' 1 Building Building
/ 2 Beo/icai Gui|di � Perm\t Fee b) �shmacd PeTromtal Cost of
uost �mction from
3. Plumbing
1 _ *— / ----- ^� �r ---'—�---
This Sec
For Official Use Only
Boi�din� PermitNumber� / uY Date |ssued:__.
Signature:
m
�ui|dinKC�mm�sinnmf|nspcc�,o|Buildings »n
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File#BP-2003-0669
APPLICANT/CONTACT PERSON Harlow Builders
ADDRESS/PHONE 336 COLES MEADOW RD (413)586-0465
PROPERTY LOCATION 33 CONZ ST
MAP 32C PARCEL 116 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Peufflut Filled out ---Fee Paid
Typeof Construction: REMOV PLASTER LATH,INSTALL INSULATION,SOUND BOARD,SHEETROCK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 052460
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Stree ommission
Z 20 a3
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
i
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r BP-2003-0669
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0669
Project# JS-2003-1102
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Harlow Builders 052460
Lot Size(sq. ft.): 15986.52 Owner: SANSOM FRANK T&
Zoning: URC Applicant: Harlow Builders
AT: 33 CONZ ST
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586-0465
Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:2/11/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE PLASTER LATH, INSTALL
INSULATION, SOUND BOARD,SHEETROCK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/11/03 0:00:00 678 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo