17C-125 (3) k E
ilk '� "^"Cyr�� f �vIn ;tljamptoli
4 � � It lSb RCt�iiL({tb
DEPT Of BUILDING INS"MT ONS _
NORTNAM!'TON ` OP aurtDr'c trrsneC 100 1s
212 Main Strcet ' Municipal Building m
Northampton, :%facs. 01060
� `OIZICLR'S COMII'ENSATION INSURANCE AhIMAV11'
�>.�ith � principal place of business/res�dcncc at:
_ (rte._ � • -onc f - Ll
do hereby certify, under the pains at)d penalties of perju)�, _hat
I
am ain employer providing; th.- iollowinn w0i'kcr's cou]I1cn2_.�0:) Covc. ;c (�lr n)ti'
enlplcvccs ',vor�.Ing on tills y)b
I am a Sole propl-,etor, general Cons—actor or hoaieowner (ci-,Cie oee) Lrid have h!red
t11c contrac-,ors 'Jste,' below wl,'Io h2ve the '-'vo[k'ei'S CQr=:� en�'�On 'pCl!CIeS
Co" rf otie, ?gum'[•=;) (c ,11 „:o�. Date)
(NIaMC of C0Ll(T2 CIOr) (IJ1SlIdt!CC Como ;vPoi c�' \'wnccr) (L\T it ion Dzte)
(Name of Contractor) (IfIS U-,MG Conip'i'u)./PoGcy Nun 1, ) (TSpi,--uon Datc)
(1 2I]C Cf C7 lI CIC,i) - (IIJSZ1ict1C.° LOIliIwS:�/h011�' Ill!1]]i_ ) (I \�
3i On 1.7310)
(enar3��d!�coca)c'u_:irncx_:.r;to ar]ud::alcKiac:cK: p.1t._r_,v;�',o�I)cm�nC-oa)
( ) I am a sole prolr.]etor and have no one v"01 kids for me_
O 1 am a home 0"vilcr perforinif"S all Lie work myself.
NOTY:picx be ---r,d:.� Jc I or_aauc ""1 'In lay J>:z •to L�^, ain z G_. C r pair"'f v.I'd..dL:�of
ON mc(c a---t.`sr_L--,rj in u',•:c'_i ttr_l�nyxn�v�.:rc,id:�a-Cxl uh- Qo�.�"_� zx'm,.�:tca-r_'tlr'r_n ;�x c11;r a-r.:d�c.±to t<
cnployc3 ua «zi t:c c-_im ru1(G LI S2 I(5)) :-pptict.cn try e t ouuo�o (or c L— u{ rn n r Y
Icy]manic of c�c�p1oVK under(1�o Work''(Ccxn;rari.lica/.cX
(u-i,--L.od(.hst>copy of thi.ct.f-1—Y tx f -r-.vl.od to(tw Pct—t —r off—of U— w Cot ttx
�pvm(Sc vv1['c-lion a-u7 ttvt f_i)(�c w accurc wvcT�,�,uncicr scclion 2SA cI1,{OL 152 on la.d to t.`r:ir;ps>v°n o(c'i`"n'n%]{�''ltics
co�of a fur of Iy to S I,500.00 n:xSJOr crpu-iiocJx�c'tt o(up torn, )—r M a xi)t�hJo Lo Cx fcMn o(a Stvp W yr O:�Su and a
Gm o(S 100.00+day (Eauxa nr_
I� PcT'n)Jt Nuunbcs
S[�na n of 1,icc�xs�..clPcrmittcc ACC _.
SECTION 8=CONSTRUCTION SERVICES
Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : s� � ,�""0
License Num er
1 ►�n� �11`- �� -cry
Address Expiratiol Date
Signature Telepholl ne
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION',10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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.
igned Affidavit Attached Yes....... No...... ❑
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
r
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
� [ N 5- DESCRIPTION OF P OPO ED WOR K(check a I a ffcable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
A
'4q
lteration of existing bedroom Yes_ No Adding new edroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
i, .
IN d
� � f
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?A
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
SECTIQN 7a •OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS,A0EN,1"tiR CONTRACTOR APPLIES FOR BUILDING PERMIT
ffyk—OLYLk Ci �r M vy\CL as Owner of the subject property
hereby authorize r I %.,J irv��� to act on
my behalf, in all ma ters relati e to WorX authorized by this building permit application.
ff-2e,tZA4;—
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that a statements and information on the foregoing application are true and accurate, to the best of my
knowledge and beli f.
igned under the pains a d penalties of perjury.
Print Name
� a
Signature of Owner/Age Date
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
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO k' 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:
S „♦
Northampton
B i i g Department
Z OW Main Street A
o m 100
K F BUILDING INS f pto n, MA 01060 is
THAMI►TON M
p 240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'SE CTION!1-SITE INFORMATION
This sert�on to be corrlp'f etc by o#fi Cq
1.1 Property Address:
Map Lot
Unit'
AL a, fflap�f - 77,7,7777
ne 0ve I istr ct
EfRt$t.C�itCict` „ :' CBI trtct
SECTION^2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
GC Vh-Z
Name(Print) Current Mailing Address:
Telephone
L2.2 ature
'
Authorized Agent:
Name(Print) 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 (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 =(1 + 2 + 3 +4+ 5) Check Number
This Section For Official Use Only
Building Permit N mber:
u �� � Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
69 NORTH MAPLE ST BP-2000-1180
GIs#: COMMONWEALTH OF MASSACHUSETTS
*,Map:Block: 17C- 125 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1180
Project# JS-2000-2067
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Cyrus Newman 064690
Lot Size(sq.fQ: 9888.1 2 Owner: SIMEONE MARIO A&FLORICE B
Zoning.URB Applicant: Cyrus Newman
AT. 69 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:6126100 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI P & SH I N G LE ROO F
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 6/26/00 0:00:00 2236 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo