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
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El
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Map` 1ot � �tlnit
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C. ef
Z istrict
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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