17C-002 (4) I II
� I �
CJ i
0 f7
- i
I � I
t
d�-
�y
LOG
i � ! G1 d
f
i
O --
I i I
I I
i
TI
�1VFfff
{ a �•z��;1 n� �nztll�tlil�lfnii -- ----
DEPARTMENT OP 13UILDITjC I?JSPLCI'fOl'S
212 Main Street ' Municipal Building <
Northampton, Mass. 01060
WORKER'S CONTENSATION 1NSURAN(T AYFIMA-VIT
--- -- /L1c�n vme, -
wah a principal place of businesslesidence at
(strreUcit}''satc�zip)
del her certify, uDder the pains and penalties of penury, Am
( i an an employer providing the following v,oikcrs coverage fog tnv
WOl king on illls job:
(1nSl1UZU: CoQpa.IIy) (Policy NU-alber) (Expiratson Date)
i and a sole propnetor, general contactor to homem,ne: (circ',e on& ant leave lured
th,e contractors Red Wiwi Aco have the tOho',��� C�'Ort:�rS COihi)eRS3i:On pokev
rc of COnCI 1CL r) (Inst:r:nc Co1:�r.a:;`/PeGc; *',a„i: Iiz: : tio, Ga:,c)
r+ame of n
Cotrac�cr'
(N me of Conmanor) (>�isuranc Com- :nyTolicr Numi _rj Ex^i;.:!ior. Dale)
(=.a.,d+:adSiti iJ c'xct iFr.cc�-_.ur:to iat}udc i.:formi:ioo ps:auiin�, eii c..�:-��::•.1
t ? i i�rn a sole proprietor and have no One 1;c;ri:irg for :mc
( j 1 am a home owner performing all tfle wore: �nvse!f.
'JOIF;:plcsc be n�ra:c t!ts:�ti'.:ilc b.xir_o�tiixt3�+fx�c�:r�lcry;>-i.m to d�c��:�•vn��cirr_r,ct:st t,c_ai7 w^r1,<rl s d«c!l:❑ cf
r_r t-K"C tfL_❑t}irco uni,s in«f d+t_'x
r.:rdo}r:�ua:ct the wo:4:a'1 Act(GL152�-z1(5)).r.�;.'.sa:icn by n h�;acou,rr:cr a I:��:_•<<c�,�:::::: .p n^.i-roc l!r
1<�il c; u:oCan xu4�lo}x uri�er t:.4 ll'xiCOra Ccxv�azul�<�i:`.<t.
i uo<'.tst wd alt a r'j,y o1 ttru etnt«zvst¢uy bo forw'wdal to 11� Oil;cd Of I:::,u Caro for tlm
c t'cra�e'oc f calioc and ttut f:ilurc to!-azc-o 'CTRL to sccUea 25A of MCL 152 can 1cPd to d,c in,pon ion of=:dra pct'-1 lies
arms ^g of a fmc of up to S1,500.00 nttdlor iris xin l of up to o,ti�t J e�j d�il rrrut:ict is r.i�x,n M stc"WcrY 0:-'�-nr'd a
fux of S l OO.0tj i dly LFAin:1 ar_
Fcr 5�+:t,rr�.a1 urr:.ply
-- � � Pcrinit NtunG�r _�_----------
,� S1 rc o A=
SECTION 8 -::CONSTRUCTION SERVICES
8-1-licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :_ v S mcn _ 077 41 j
License Number
Addres Expiration D e
Sig, pure Telephone
9"Re istered,Home lni'rovemertCon'tra'ctor` V�%„�" �,„” '`; `" � Not Applicable ❑
g p .A'��4pt i5,.¢.i. A, �.fiA «.w+�-t.., �,.�+.,r.:�,�E ,,+�':�.6U
7
Company Name a Registration ,Number
ft _
Ad r ss Expiratio Date
Ley C ?C@ (s'" 2 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.. . . ❑
em�cri
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 oN�ner 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 i?,uildin�, Official, that he/she shall be
responsible for all such tiN ork performed under the buildinL, permit.
As actin- Construction Supervisor your presence on the job site will be rcrluired from time to t:ntc, du:ing and upull
completion of the work fc 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 Ltrws Imrctatcd, you may be liable for person(;
you hire to perform work for ou under this permit.
The undersigned "homew ner" certifies and assumes respon�ibility for conic li rnc_ ,v 1.1' the Stag• [3u:lding Code. of
Nonhanipton Ordinances, state and Local Zonin(_', Laws and State of ylas,<tchusctts General Alm )'atcd
Homeowner Signature --- -
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all a_ licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Dernolitio r❑ New Signs Decks [ ] Siding " Other f
Description of Proposed Work:
_ _�1'�
y
- terati;n of existing bedroom _Yes No Adding new bedroom_ - Yes _ -- No
� t:a-hed Narrative Renovating unfinished basement Ye-
l 3rs -ttached Roll-[---Sheet [
6a. If'New:fiouse;`and"or''addition to`existing-housing; complete`the following
of building - One Family _ _ Two Family Other
N'u,iiber of rooms in each family unit. Number of Bathrooms_____--_--__
Is t--ere a garage attached? _
d Proposed Square footage of new construction. Dimensions
vr;nDer of stories?
111,f-i,od of I-ea,ing? F or Woodst-,,f..
Frergy Conservation Compliance "Jascheck Energy Compliance form at;a ec-
Tyce of construction _
is construction within 100 ft. of wetlands? _ Yes - _ No. Is constructio- witnin 100 yr occ;pla�n - -__Yes
:ep_'n of basement or cellar floor below finished grade
Nilk building conform to the Building and Zoning regulations? _ Yes No .
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
,,.hl
n al I,I,--ite� relative io , _ �_i I orz-�c ry th d ear t app t
ature of Owner Drae
E'
i _ec!are .l at the staternents and information on the foregcmg application are tr.,_ and 1A) ,i - ,..st or
knowledge and belief.
f �Jnec -rider the pains and penalties of per ury
Ile -
f df r + Date -
_ Own C _
G
lb
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMI'I' CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be rihcd in by
BLlildirg Department
Lot Size
Frontage
Setbacks Front ---
Side L, R: L: R:
Rear
Building Height �- � - ---
13ldg. Square Footage 4% -- ---- —-- - --
Open Space Footage %
(Lot area minus bldg&payed
ark in�j
' of Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding/ever been issued for/on the site'
NO _ DON'T KNOW Y YES
IF YES, date issued:__
IF YES: Was the permit r,;corded at the Registry of Deeds?
NO ll f) TT KNOW YES
IF YES: enter Book _--- Page - --_ - - and/cr Docum.,nt 1:
H. Does the site c,n*,ain a brook, body of water or wetlands? NO [�Ok :NOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Cornillission2
Needs to be obtained fined - ___Obtained _ Date ISSUed
C_ Do any signs exist on the property? YES -
NU
IF YES, describe size, type and location:_
D. Are there any proposed changes to or additions of signs intended for the ?YES NO
IF YES, descr be size, type and location:_ _
,
-- - ice,
�- Git of Northampton '8fatusppo, Per If
nt
-° BL]ilding Department CurbCut/,Drvew er 'it
2 2 Main Street Sewer/,SIC"Aval(ab
zm-
�Q 2 '61 Room 100 Water? e vaa a . �.^
y1"N53 �yYb _M'
North�mptbn, MA 01060 TwoSetsoflafr (1, F 1
phone 413.597 1240 Fax 413.587.1272 Plbt/Ste P�lans�
.x
Other Speclfyr „ art ' • _ � .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
------------- -----
SECTION 1 - SITE INFORMATION
This section to be completed by office
1 1 Property Address
Q06 Map _ Lot Unit
(�fif C C �� floc, Zone - Overlay District _
Elm St. District_ __ CB District___- _____--
SECTION 2 - PROPERTY OVINERSHIP/AUTHORIZED AGENT
- - -------- --- — - ----------
2.1-Owner of Record:
-
- r NA.,
yin -
Telephone
2.2 Authorize
rt) urren, M< ih, Aoaress
s-:t- Telephone
SECTION 3__ESTIMATED CONSTRUCTION COSTS
b_ permit appl ;:ant -- - --- -- --
-- -- --- << r )a,ea �,cst (Dollars) To Cnly
h t)ffi���al _ � - ---
�Jing Ll (a) Building Permit Fee �-
(b) timated Total Cost o'
C �nst'uction fr r,i -
- - Building Permit Fee
ca iH\,SAC
r
Cntc N her d This Section-For Official Use Only
---- --- --
3uwlcc;,ng Permit Number:_ — _ Date
i
�� ;ignatare:
B.rld!ng Commissioner/Inspector of Buildings ��t
File#BP-2003-0651
APPLICANT/CONTACT PERSON MONTGOMERY JESSE&HEATHER A
ADDRESS/PHONE 46 OAK ST (413)584-4941 Q
PROPERTY LOCATION 46 OAK ST
MAP 17C PARCEL 002 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMOVE EXTRA STAIRCASE REWORK INTERIOR WALL&CONVERT 2 FAMILY
TO ONE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Commission
J
L Z a a3
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.
>
�
,
j ot�l, (
�
�
46 OAK ST BP-2003.0651
GIS#: COM ,YjEALTH OF MASSACHUSETTS
Map:Block: 17C-002 TY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0651
Project# JS-2003-1073
Est.Cost: $5200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(ss . ft.): 19602.00 Owner: MONTGOMERY JESSE&HEATHER A
TT 11 Anrr;r,,.�t�I��,nniT(;OMERY JFSSF & HEATHER A
2oriTIg: — ,
AT: 46 OAK ST
Applicant Address: Phone: Insurance:
46 OAK ST (413) 584-4941 O
FLORENCEMA01062 ISSUED ON:213103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE EXTRA STAIRCASE, REWORK
INTERIOR WALL & CONVERT 2 FAMILY TO ONE
POST THIS CARD SO IT IS VISIBLE FROM rHE 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: Q f-t 3
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 6 k g^q-d5 --,L O
THIS PERMIT MAY BE REVOKED BY THE CITY OF N RTHAMPTON UPON VIOLATION,OF
ANY OF ITS RULES AND REGULATIONS.
.r
Certificate of Occupancy i nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/3;'03 0:00:00 1606 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo