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29-225 (2)
x 2'O G"vr3%c, �y E ( IN of ■3%A Cll IIL 1(15 c>` DEPARTMENT 01' DU(f1DF,�\G INSPf'CT1Ot:S 212 Main Street ' Municipal Buddin,- Northampton, Mass. 01060 WOI(V'S C0�iU-)ENSATI0N MSURANCE ?.f,hlJ)AVIT -- i.--. -- 1� - i N (1j CCU s rJp rnJittcc) — v,�th a prulcipal place of busme'ss/residence at S - do hereby certiy, under the pains and pe1121ties ofpenury, ?ha; ( ) 12-m an employer providin- the folloy,"11w %vor'kcl's colnocns::,,er:� cover e {or Jm C111p;OviceS Wo[i'lng, off U1151ob -- C' COM Y) ( ) I aml a sole propr etor genera] contractor or ho-meow-oer (ctcie one) znd have hired Lhe coax actors iisie- below who have the fol]ovf-1i]2 �or� ergs co pe s don pe!!cles (I`�IIS'il^. 0; CG:":;!Ci0r1 (lnR!rT311C:. �_Ot11Da11�'/PGUC•--?��UtTT"::) (i.>:;)f;ll:)pii I��ICj (N me Of COn(T2clor) -- Ra1-IlMDCC COIDDcIl`'/PGhC-,• N'tLMC-;r) — (Name of COn132CIOT) C�suranc Cori n�/PoGc) ;urb r) (E�pu;:riO�l Date) (1�`z IC of COnI-F Ci0r) - - Q lnnc Com{ ]7y/I'olicy ttumiy�) �L��;�<<Jtion D,tc) if occc:..,r ro r.�_� infon:��ci ec Ix�tr.ia�:r to X11 orr coo) am a sole proprietor and have no one working for me. ( ) I and a home owner perforrt>_ing all the work myself. NOTE:plc sc tx cax c ty r,µJc t cn v nµ{re cal ry tr:ces to d c�_ a Y c ruJ.•oi m.u..c11 of ¢cx aocc�•�.n t.`�'rr_ �in u'._;c?�tIx 6rzxw,D'=rc ,do oc Oct th.- o•an`_.,z rtcr_r`thcc'.n�r ex --,,::lJy ari:d�-ni to r., r�oloyc�unG�Ch.;�•ui;rf� _��r'�(GL1 S7_-<I(S)),:ppliczt�or,Fry a ho;:ubo,:x:fc:r Lr cc FK Mln r y n,&ncc lrc lcs>I naair oC en�xployrr uodcr clw Wor�cla Co�ocn.l;oa nd f under rt..�nd[fva.>copy oC(Iii,aiL. m.y bo f,--,id to tbo Dcswr�r-sv of Indur-ricJ nc�ad rlj OfL_of lr-_for tt. �vc�,gc vcriGclioa aid 11h.t L•iJv�c w c«un covcrasc ra-�ioctioci 25 A cr MGL 153 on Icd to tt-.:--I;iOo of aimi -'J pcn�wcs comis:uzg of-fine of up to S I X00.00�:sN x entniw ul of up to ocr}2 cal ci.il Pau Jci�O tx form of a Stop Wort;Ordc LZA a Gro oC S 100.00.day Fcr D _ -- ST"IMltn' of Liariscc/}'crmiucc E CTi 8-CONSTRUCTION SERVICES d.1 Licensed Construction Su erv'sor: Not Applicable,❑ Name of License Holder: C d �� ' 0 License Numb LAA S G Q -3T7-7 10 Address 77 Expiration Date AW Signature Telephone SPERM at�` _ .,,� Not Applicable ❑ 1 cc 2� Company Name Registr�n Number &tL4 c C11 12/07 Address .. `` Expiration Die Telephone cq`1 �Z SECTifl,N 10-WORKERS'COMPENSATION INSLIR411iiICE It,,FIDAVIT(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 the building permit. gned Affidavit Attached Yes....... 10 No...... ❑ 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 0 1 ch k L e:S- C t New House ❑ Addition ❑ Replaceme t Windows Alteration(s) ❑ Roofing ❑ Or Doors W Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: r P&-- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes X_No Plans Attached Roll ❑ - Sheet❑ t a. Use of building : One Family_ Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? 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? 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 OR2�;O t'TRAC.T&tAPPLI TOA ODU=DING PERMIT l as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date QJM C 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. igned under the pain nd enalties of perjur . f rn)(A C C;� It.,�2c1 Print Name Signature of Owner/Agent Date J 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. Ar there any proposed changes to or additions of signs intended for the property ?YES No T IF YES, describe size, type and location: F n. U � U4 Lb U f Northampton A 7 SM ng Department 21 Main Street gs�tlOtt�G 110%S om 100 taOR?HAMIrI(' N+ ampton, MA 01060 phone 413-587.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION Thlsy iaiito ited y � 1.1 Property Address: y , x Fh \f g 4+ SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: me(Print) Current Mailing Address: Telephone S6 Signature 2.2 Authorize A ent -7 Name(Print) Current Mailing Address: Signature Telephone SC ION I;ESTIMATED,CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building , (a)Building Permit Fee 2. Electrical (b) Estimated Total C©5 of Coristruction'from 5 " 3. Plumbing ,1 Suilding.Permit f<ee 4. Mechanical (HVAC) _ 5. Fire Protection 6. Total =(1 + 2 + 3 +4 + 5) Check Number `"' This Section I:orOfficial Use Only u.ilding Permit Number: Date Issued. A , Signature,: Building CgmMiWonerflnTpector of Bull;lirtgs Date r 4 �... _ f 144 ACREBROOK DR BP-2001-0013 GIs#: COMMONWEALTH OF MASSACHUSETTS MM.Block:29—225 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-001.3 Project# JS-2001-0028 Est.Cost:$2500.00 Fe 25.00 PERMISSION IS HERE B Y GRANTED TO: Const.Class: Contractor: License: Use Group: Paul McCutcheon 100218 Lot S' sq.ft.): 15158.88 Owner: BOWYER HOLLY zoning:u>za. Annlicant: Paul McCutcheon AT: 144 ACREBROOK DR Annlicant Address: Phone: Insurance: 87 Chestnut St (413)584-3352 FLORENCEMA01062 ISSUED ON:717/00 0:00.00 TO PERFORM THE FOLLOWING WORK.-REPLACE SINGLE DOUBLE HUNG W/SLIDER POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:(!)K 7 -d O THIS PERMIT MAY BE REVOKED BY THE CIT F NORTHAMPTON UPON VIOLATIO OF ANY OF ITS RULES AND REGULA IONS. '' Certificate of Occul2an si ature: Fee Type. Receipt No: Date Paid: Check No: Amount: Building 717/00 0:00:00 4558 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo r