25C-046 (5) a E (rii of Part liarltptoll - _-
Rf �Zcssnc{lrttctta' _
Q DEPARTMENT OP BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, ATass. 01060
WOR10ER'S CO'iVTPENSATTON. MSURANCE AFFMeAv `i.
Qiccus.^rljxrm�ttcc) "
-- (phone-,)
(sar t/ci ty/sIal r P)
do hereby certify, under the pains and penalties of pcg'ury, ha
( ) I am an mployer providing the followine %�,orkcr's comocnsadon cove g.0 for lin
etuptovecs w rung on tills job:
(Polio 1;u-ter) --- (r.:-piruon Dzsr)
( ) I am z s le proprietor, general contractor or homeowner (c' cie one) and have hired
the coon act rs listed below wbo hzve the following woEkef s compnsa6on policies:
(i+Qflle Oi Onmlaor) (lns mncz Cotrloany/l obc NllumhL_-) �?;)1iJGQn I�IIC)
(Name of Co�otraaor) (Insuranc;. ComoaIl-,'/Pot1C' Num6cr) (-Lx-pir,lion Date)
I
(Name of Cob.aaeto.) (Lasuraac Compan)'/Pot;cy tv,m,b�l) (Exaim6on Date)
i
ame of Contractor) (Insurance Compaay/Pobcy NUM)YZI) - (Expiration Dais).
(na,.c!s �ocaJ shcC ifno�—u^Lo ccut�iafocm,�oo pczU.iniag to.1.1
I am a sole proprietor and have no one worl,-ing for me.
( ) I am.a home owner performing all the work myself.
NOTE:plea be cvrarc ti_wj_:a bomcowocrz lobo Ploy pe-son:w da�•;�,--•, Cr rcpQz work on a of
not snort t ` w_tars in u'hieb the bocnoownc rides«oc[be Vvao,3 zp • tl,- L-c 0( , oeo;d=d to be
employes unGc the oa An(GLl -WU=aon by n bomoowac fns:Gc==or permit sr=y c idcorr ll:c
tcsal-LLtL'of en o=Ployx under di.Work.e.Coo� Act_
1 undrnL—d dL4-copy of thi.—J—s y bo rorarnrd.ed L.tba DW_j=cW or ln�icr Ac &.a&OM of Irrv—for the
oovc�v=iretion a_-td th_.t_f lltmc-so seE+srrkavcr .r`tsdcz-'=GOn 25 A nC MOL,151 can led to the imposaioa of-imi-1 pcuilli-
o up en S 1,300.00 and/or oCup to o«yev rad dv1J pm.tio in he form o(e Stop Wort Orde and s
oCSI fLy.��
For d�.rtm=.=1 u—only
J Pclmlt 1`Iumbcr
1`-jap. Lot K
Sit�oaturr n Litxryst CIPCrrYu, ice at=e --
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10=STRUCTURAL.PEER REVIEW(T$0 CMR°1-1011 ;
x ..
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 -OWNER AUTHORIZATION TO-BE COMPLETEQ WHEN'
OWNERS AGENT OR CONTRACTOR APPLIES:F"OR BUILDING'PERMIT
as Owner of the subject property
i
hereby authorize
fl,�.3 �� G� ✓t-v�-1L 'to
act on my behalf,in all matters relative to work authorized by this building permit application.
1 Signature of Owner Date
F
Z1 C.if ,L�
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.
Si ng ed under the pains and penalties of penury.
Print Name
i
Signature of Owner/Agent Date
SECTfON12.;.GONSTRUCTION,SERVICES. ,
10.1 Licensed Construction Su sor: Not Applicable ❑
d G
Name of License Holder 3 S 1(
License Number
y f -
s
Address Expiration Date
i
i
Signature Telephone
SECTION 13-WORKERS'COMPENSATION.INSURANCE-AFFIDAVIT;(IN G.L.c 452;:§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 0 No 0
r
Versionl.7 Commercial Building Permit May 15,2000
THXCN oii
SECTION 9-PROFEH310NAL DESIGN�AND CONSTFtUCTION�SER1pES F®RBUIt.DINGS-ANC1 SFtLtGTF1RESJIEGFO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR'116 CO1�iTA1NING MORE odic F OF ENCLOSED SPFiCE)
9.1 Registered Architect:
3 Not Applicable ❑
Name(Registrant):
( Registration Number
i
Address
i Expiration Date `
Signature ! Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
� I �
Address Registration Number
Signature Telephone Expiration Date
i
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
E i
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
I i
i
Address Registration Number
I i
Signature Telephone Expiration Date
9.3 General Contractor
j Not Applicable ❑
Company Name:
c
i
Responsible In Charge of Construction
r i
i I
Address
Signature Telephone
v
f +
Versionl.7 Commercial Building Permit May 15,2000
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:' ' R: L:i —i R:L}
Rear
-B ildmg Heirif
Bldg.Square Footage (— % r—
Open Space Footage % --
(Lot area minus bldg&paved
aridn )
#of Parking Spaces
Fill:
volume&Location) i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON7 KNOW Q YES 0
i
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds? % "r
NO 0 DON r KNOW 0 YES 0
IF YES: enter Book j Page, and/or Document#[
B. Does the site contain a brook, body of water or wetlands? NO k.V DON7 KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C.` Do any signs exist on the property? YES 0 NO
t
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:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES,then a Northampton Storm Water Management Permitfrom the DPW is required.
A
Versionl.7 Commercial Building.Permit May 15,2000
SEETIUN�4=.CyO1VSTRtIGTLQN SERVICES.FORPR�ECTS,�ESS'THAN 35,OOQ'
CCIBIGFEETOEENCIJ EQSRA -E.
Interior Alterations ❑ Existing Wall Signs ❑ Demolition /Repairs Additions ❑ Accessory Building❑
C . ...�
Exterior Alteration Q Existing Ground Sign❑ New Signs Roofing'❑ Change of Use❑ Other❑
a
Brief Description }Enter a brief description here. R lvff',?r #,Z tiC Pc,tf'H
Of Proposed Work:
I
SECTION 5-USE GROUP AND CONSTRJC'CION°TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
❑ A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ® R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:J
M Mixed Use Specify:
S Special Use El Specify I I
COMPL ETE THIS:SEGI tON iF E<ISTIN,G BUILDING UL�IDERGb11 GREt AQQITIONSAtdDfOR.CkiANGE t[V USE
. _ __. _ ___ ._ .� 1_.-. _ .
Existing Use Group. Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):i I
SECTION 68UILD�INGHEtGHT ANtQAREA. -
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION
1 � � •,t, 4..
Floor Area per Floor(sf)
151 151 E
2nd
2nd i
3rd 3rd r
4m "
4m i I
Total Area(so Total Proposed New Construction(sf)
Total Height(ft)
I Total Height ft T
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System-
Public ❑ Private ❑ Zones I Outside Flood Zone[:] Municipal On site disposal system E]
Version 1 J Commercial Building Permit May 15,2000
City of Northampton
-�- tttaing
Department
212 Main Street
Room 100
Northampton, MA 01060
AY _gh(.%'13-587-1240 Fax 413-587-1272
i O ec
F APPLICATION TO CQNSTRUCT,)REPAIlk,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING 4
c - OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1=S1TE•tNFORMATION x>
- -1 1 Prooertyy4ddres `Tkt�Secfton tou6e compfed 6e�ffice
m
13 W CC 1) 17 Lo Urut
-
? l ones , -Or►etfia�`Dis�'nc�
f I ._rl�StDisfrttfF .� CB Drs�ct � � �t.
SECTION 2 PROPERTY OWNERS�IIPIACtTHOR1ZEEkAGENT
2.9 Owner of Record:
t:IGrl4i1P 1rlrf KE ! � l l� t;uC.XLANj) `t6rG-1tT`S
i
Name(Print) v w.D C L ik i2lt 4 / Current Mailing Address: �v :1-ri` I• ' V
, i 1 E 5 44,17
Signature �'E N T Telephone
2.2 Authorized Agent:
�rt��p CtA.l1C j j tib ;BtLKL4NA HEIGHr.S
Name(Print) / Current Mailing Address:
Signature Telephone
SECTION-3-.hSTIMATEDCONSTRUGTIDN COSTS
Item Estimated Cost(Dollars)to be OffciaL Use 0ialy
completed by ermit applicant
1. Building 3� i (a Building=Permit Fee I
i s
7
j (b):Coota1;Cost of 2. Electrical ast cti '6.
3. Plumbing l" Butldrng Permit Fee
1 >;
4. Mechanical(HVAC) l
5.Fire Protection i C
6. Total (1 +2+3+4+5) Check Number
This[Section'FoC OfflcialUse Onl
Burldi"" PermrrGlumber; Elate: -
IssUed
r
Signatures
Building.Commissionerllnspedor of Buildings Date
h
File#BP-2005-1100
APPLICANT/CONTACT PERSON David Clark
ADDRESS/PHONE 116 Rockland Hgts NORTHAMPTON (413)586-4347
PROPERTY LOCATION 9 WOODBINE AVE
MAP 25C PARCEL 046 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_ypeof Construction: REPAIR PORCH DECKING FRAME ROOF&RAILINGS AS NEEDED
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License 000635
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,VMATION PRESENTED:
pproved 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 Street ommission
5-/w/
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.
9 WOODBINE AVE BP-2005-1100
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-046 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1100
Project# IS-2005-1494
Est. Cost: $3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: David Clark 000635
Lot Size(sy. ft.): 4094.64 Owner: JAESCKE RICHARD E&SANDRA H
Zoning:URB Applicant: David Clark
AT: 9 WOODBINE AVE
Applicant Address: Phone: Insurance:
116 Rockland Hgts (413) 586-4347
NORTHAMPTON MAO 1060 ISSUED ON.5 116105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH, DECKING, FRAME, ROOF &
RAILINGS AS NEEDED
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:
FeeType: Date Paid: Amount:
Building 5/16/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo