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32C-339 (10) SECTION$r CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone r' JJNJ 11, _, ��, u_,, Not Applicable ❑ n _ t l 1 7s- ComDanv ame ,n Registration Number Address ` / Expiratio Date Telep one �7 3 .SECTION 16 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 the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ r .,. -' � t 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, tate and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5 DESCR�IP71dW&PROPOSED WORK(check�all applicable x� Ts ',:bs New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ Siding[L+---'Other [ ] Brief Description of Proposed Work: -e �' rd°f t?a rC LL A , Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a !# Newhousearidpad°tlition°to'exist�ng 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 l A. Has a Special Permit/Variance/Finding ev been issued for/on the site? NO DON'T KNOW ES 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 nd/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 Conservatl n Commission? Needs to be obtained Obtained Date Issue 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 IF YES, describe size, type and location: City of Northampton 7Z7'1,, u n Department ain Street om 100 � " 3 Z(l or ! ton, MA 01060 . phone 4 3 8-7r]240 Fax 413-587.1272 er -- ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This sectionJ be comptetedaby office x1j, El R Map` 1ot � �tlnit A-4 C. ef Z istrict y m Elm.St.'District zY C4 District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pri t) Current M cling Address: Telephone Signature 2.2 Authorized Agent: �a✓ e4lLrG SIG'k kl;eta c Fl o /'f, y5`�'� sf 3( Phoe%o;K &-(95Dlg Name(Pr' t) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 0 (a) Building Permit Fee 2. Electrical (b) Estim�.ted Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) l Q D Do. Check Number This Section For Official Use Only Building Permit,Number: Date°'Issued: Signature: Building Commissioner/Inspector of Buildings Date lox* .::. Y. „� � BP-2003-0220 R GIs#: COMMONWEALTH OF MASSACHUSETTS s -3 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: roofing BUILDING PERMIT Permit# BP-2003-0220 Project# JS-2003-0396 Est. Cost: $10000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LYLE ROOFING & SIDING 118751 Lot Size(sq.ft.): 8886.24 Owner: SIENKIEWICZ CHARLENE Zoning:URC/GB Applicant: LYLE ROOFING & SIDING AT. 2 KINGSLEY AVE Applicant Address: Phone: Insurance: 1851 NORTHAMPTON ST (413) 533-6012 HOLYOKEMA01040 ISSUED ON:913102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR ROOF, PORCH & INSTALL SIDING 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 9/3/02 0:00:00 304 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo