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Do not use for International Mail See reverse Sent t Judith Jacobson Street&Number 41 Sovereign Way Post Office,State,&ZIP Code Florence, MA 01062 Postage $ J .� Certified Fee Special Delivery Fee Restricted Delive Retum Receipt 164 Pg to — Whom&Date Doliyeted Q Retum Receipt Sho (nWh Q Date,&Addressee's dres?, 0 TOTAL Postage&F.40~C' x'41 07 Postmark or Date E `o LL U) a fnT 0 -- (!id ) of jnufllailiptoil A d ,31a�ancllnccfla DEPARTMENT OP BU1I1DP\'G INSPECTIONS — 212 Main Street ' Municipal Building Northampton, Mars. 01060 WORICLR'S CO�fI'IINSATION [NSURAIvCE AFIIDAV17' `�---- �1�u�per1117tt��> lnclpal l)iace OI b11siTwssjres1dC11cc 2t. do hereby certify, under the pains and penalties of perjury, that I am an empioye= providing the foliovving worker's compens<aion covc:-,,,e !of my c;nlployces wol�-,ng mi this jot t c ner a:Cie one) ; �I am � sole r.onne or, general contractor or hom..ov� ( ��� ve hued the coayactors listed below who have the fol]owMP- Workers CoODDensa_Uon pelicles. IIIC of Con'::�CLO'1 --(Name of COUM-IC,01) Rasu=cc Comnan-,•/-POhcv (H.v,)Irruon Date) (Name of Contractor) Compan)-fPoLc) N1mbe ) L�pi lion Date) (Mme of Contractor) (Insurance Compauy/Pohcy Numbzr) (L ypivauon Date) (wadi Zdditic,2A vxct�r.<r_i:,;to �:KUC� �rforLU:ioa pcztaming w all ( ) I = a scle proplic.or and have no one wor4dng for me O I am a home owner perfonllmg all the work myself. NOTE:pic ac be ds:u,yIc ctD a:ar cry ��oo��jai:.�ai i; o n d�ctlar of roc a�occ tlin tbron unto in u'.��dt tlx Iw;t»o•.�.r-.-rcid~i a a�t}v�-a.:rxi�zpM:rt<r.vn Lr-c'.n z.•c crx pc;c:ily o_r_::d:-:z=i:r ir. �UTIogcr-3 undo Ltr Art(GL1 1(5)�Lf-?Aicnctt ty a ho:nca�zti7 far c hcSx a p-mn r.-y dvx lcgil ctn—of cn c oploy-w)dcr d; Wortn'a Coma>li on Act I undcraxnd dux a copy of ttuz ctiLcn>au nvy tx f--,id L.the D'j-1 x-cz1 of 1 i..isJirJ Amdrnt-�'OfLoo of Ir.•uJV>oo for dx oova &S vcrifiClioa n:.d L11--t f_ilta-c to&Cc uc coN•crnsc urk�kr zoctioa 25A of MGL 153 can Icad to the riioa of cawurul pcvehc eoaiu.mg of e fine of trp to S 1500 00 Ulx-V x rnlulwnrzr-ri oCup to Mx )TS ��l evil j�, fnxm of n sta)Wort Onic and e fim of S 100.00 a day c2 nui i In, rcr c�{:+�tn>L:Y�I a.c only 1'cnnll Numtx.r ---- - ` 1 Sil; atJn of Liz�r��JPcnnittcc T)Jt ISECTION 8-CONSTRUCTION SERVICES J Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone -�4 ��5- Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone — 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 the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ 1111000 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 ECTION 5- DESCRIPTION OF PROPOSE OR (check a 1 a I'ca le New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes `/ No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 OR CONTRACTOR'APPLIES FOR BUILDING PERMIT I :Ilk j Q ca p as Owner of the subject property hereby authorize to act on my behalf, in all matters re a ive to work aut ized by this building permit application. JA!AL Signature caner Date 641"— , as Owner/Authorized Agent hereby cleclarOfhat the statements and info ation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed and tlhe pains and penalties of per r . A011-1 'A Print Na 5'_ 2-a d Signat of Owner/Agent Date f ' 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 1 4—Sl t�t.vY �v V CJ Lot Size Frontage Setbacks Front Side L:� R: L:_ R: Rear /D Building Height D I Bldg. Square Footage % 11�`St-� � Open Space Footage % (Lot area minus bldg&paved e'f i��X 0 in #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 IF YES, describe size, type and location: +J k, th Northampton Q BU I g Department 2 Z Main Street R om 100 �� o� lLn sic it' m ton MA 01060 �FFT B!1 rt. ` 240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION — This section €o he cpmpletei! y-office 1.1 Property Address: '96, Map Lv Unit Zone a Orrewla C?istrlct x EIm,,St.'Dlstrlc# CB IDlstrict SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) J Current Mailing Addre : ( 3 1—r1T f — lid y Telephone Sigruffure 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building 6 , (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 + 2 + 3 +4 + 5) Check Number �- This Section For Official Use Only Building Permit Number: ��/ Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2000-1048 APPLICANT/CONTACT PERSON JACOBS JUDITH ADDRESS/PHONE 41 SOVEREIGN WAY (413)584-1104 Q PROPERTY LOCATION 41 SOVEREIGN WAY MAP 36 PARCEL 297 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvneof Construction:_ERECT GAZEBO New Construction Non Structural interior renovations _ Addition to Existiniz Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE^LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 Co ssion Permit from CB Architecture Committee � 2 ZoOa Signature of Building Offieial 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. 41 SOVEREIGN WAY BP-2000-1048 GIs#: COMMONWEALTH OF MASSACHUSETTS Map Block: 36-297 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:shed BUILDING PERMIT Permit# BP-2000-1048 Project# JS-2000-1720 Est.Cost: $3500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Group: Lot size(sd. ft.): 32539.32 Owner: JACOBS JUDITH Zoning: S Applicant: JACOBS JUDITH AT. 41 SOVEREIGN WAY Applicant Address: Phone: Insurance: 41 SOVEREIGN WAY (413) 584-1104 O FLORENCEMA01062-9622 ISSUED ON.•5 125100 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT GAZEBO 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: 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 5/25/00 0:00:00 882 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo k�� : �aa��-� °mac- ` �.e�' ��°-� , . 41 SOVEREIGN WAY BP-2000-1048 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Bl_k:36-297 CITY OF NORTHAMPTON Lot-00 i Permit: Building C_a ory:shed BUILDING PERMIT Permit# BP-2044-1048 Pro xect# JS-2040-1720 Est.Cost:$3500.00` Fee:$25.0 0 PERMISSION IS HEREBY GRANTED TO; Cgnst.Class: Contractor: License: Use Group. r Lot Size(sq.ft.): 32539.32 owner., 3ACOBS JUDITH Zoning:Sg Alrcant:_JACOpBS_JUDITH.. AT: 41 SOVEREIGN WAY fl trtc,ornt Address: Phi Insuruncer 41 SOVF"IGN WAY (413 584-1104 FLORENCEMA01082-9622 ISSUED ON:3/25100 0:00: TO PERFORM THE FOLLOWING YORK:ERECT GAZEBO POST G THIS� IT IS VISI$LE FRO1V,�THE STREET Inspector of Plumping Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service:,___— Meter: Footings: Rough: Rou I House# Foundation: Final• Final• �il� • Rough Frame: Gas Fire Department Fireplace/Chimney:' Rough: Oil: Insulation: Final: Smoke: Final: ""y - A", © � i THIS PERMIT MAY RE REVOKED I P&CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS MULES AND REGULATIONS. Ce i#i ate of OceggMpy ture: Fee Tune: fteint No: Date Paid: . Check No: Amount Building 5/25/00 0:00:00 882 $25.00 212 Main Street Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo