17C-124 (6) cp 1, '4 of
F
OCT 4 2000
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30
lao IL
06-20-00 14:03 DEPT OF PUBLIC SAFETY ID-14134431053 P01/01
OCT Q ZO ENERGY CONSERVATION APPLICATI-CW FORM FOR
�'... V►f-RiSr RESIDENTIAL NEW CONSTRUCTION AND ADDITIONS
{ 780 PMR.Appendix d{ef}ective 3/1/98)
r
,F�' Eie4�'ea
'gait "fume: . Site Address. 5
Applicant Address: / Shg City/Town:
a G 0(QGZ Use Group:
Date of Application:
Applic-ant Phone: 4; 35yo Application, Signature. —
CanipManm Pats(dmck ane)c
Prescriptive Package(Lifnitea to 1- or 2- family wood frame-Widings treated with fossil fuels only)
Package(A through KK from Table J5.2. lb):-_-_ Heating Degree Days(HDDm)from Table J5.2 la:
(For items d. through i., fill in all values that apply from Table J5.2)
a. Gross Wall Area sq. ft f. Wait FWsfue 13-
b. Glazing Areal sq. ft K. Floor R-Valise R
c. Glazing%(100 x bra} h. Basement wal I fl-
d, Glazing L1-yalue r- i. Slab Perimeter a.
e. Ceiling R-value R- j. Heatirig-Al UE
❑ Component Performance: "Manual Trade-Off` (Limited to wood or metal framed buildings only)
Climate Zotw(from figure J6.2.2) ❑ Zone 12 ❑ Zone 1� ❑ Zone 14
Attach Trade-Off AWksheetfrom Appendix J,(and HVAC Trade-Off Worksheet, if applicable)
❑ MASchecrk Software
Attach.Compllance Report and inspection Checklist printouts.
❑ Systems Analysis OR E3 Renewable Energy Sources
Attach Mass Registered Architect or Engineer Analysis
ALTERNATIVE FOR ADDITIONS ONLY:
a. Gross Wall +Ceiling Area 8�sq. ft. b. Glazing Areal 81 sq.ft. c Glazing j,(100 x b+a) q,RI g6
❑ ADDITION with Glazing%(c.)up to 40%may use 780 CMR Table J1.1.2.3.1 below:
MAXIMUM U•value Minimum R•Values
Fenestration Ceiling Wall Floor Sasenrent Wall I Slab Perimeter, Dept
fk39— '� R-37 R-I�3 R-19 R 1Q r+ nWa_
10,4 ft.
❑ -SUNROOM-addition(greattr than 40%gl zing-to-wall and ceiling gross area)
Attach "Consumer information Form"from 780 CMR Appendir8.
Official's Name: Official's Signature:
Application Approved ❑ Denied ❑ Date of Approval>Denial.
Raas on(5)at r Knial: (provide additional details as needed on back side)
Gbzinz Ams may be ckl4er-3Wut*s Opening or Unit Di on
06-26-09 14:81 TO:DEPT OF PUBLIC SAFETY FROM:413 4999444 P01
B B Gl ifl! of 'Nart aillpfun
9 � �aiaRCltnSrttS
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
x
(licenseelpermittee)
with a principal place of business/residence at:
,�.2 G/
6M 0(062— (phone#)q(l SU` 3
(street city/stateJap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
I am a sole proprietor, general contractor o omeowner cle one) and have hired
e contractors listed below who have the following wor e s compensation policies:
5AM (SKOW6* tab, � i�wuat, ( u�iPK 7�Y rt 2�
✓ (Name of Contractor) (Insurance Company/Policy Number) (Expiratio Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insuran(--Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Atta-h additioaal sheet if nacenjry to inchrde infw on pertaining to all coats rs)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please ter aware that viUo homeowners who employ pawns to do msiataia ooash tioa or repair work-a dwelling of
not more than throe twits in which the botneowner resides or on the gry mds appurteaaat thereto are not gwerally comidacd to be
employers under the work oompcas4oa Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal staters of an employer under the Wodcor's Compensation Act.
I undavtAad that a copy of thin ct dca eat may be forwarded to the Dtpartn of Industrial Aec idoats'Office of 1:1=900e for the
covmge verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of aiminal pea tW-
oomisdrig of a fine of up to S 1,500.00 and/or imprison of up to one year and civil pcn&Wcs in the form of a Stop Work Order and a
fine of S 100.00 a day ageing me.
gPermit al trse�y
Number
(ti 10-'z—Do Lot#
J—SSi f Lic=see/Pe ittee Dare
'SECTI'ON 8-WNSTRUCTIONI SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
nE t tit
' T,,?� o Applica e
Company Name Registration Number
Address Expiration Date
Telephone
SECTION,10-WORKERS*COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)j
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...... ❑
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
S R R heck' ! a "licable
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitionor New Signs [ ] Decks [ ] 5a* Siding[ ] Other[ ]
Brief Description of Proposed Work: JKR. 1A V)E. 2 sXs-S L& SJW1"WAM r t4go— t jr,,41e„114,
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 2
c. Is there a garage attached? —
2$-b
d. Proposed Square footage of new construction. Dimensions 16 X I 0
e. Number of stories? 2.
f. Method of heating? VE:(-_& V_L%,L,O Fireplaces or Woodstoves�Number of each �—
a�s-
46
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction Wnfl.17 %R%AJ_
i. Is construction within 100 ft. of wetlands? Yes 1\ No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade 14 4&!9= 11
k. Will building conform to the Building and Zoning regulations? X Yes No .
I. Septic Tank City Sewer _ Private well City water Supply _
SEOT1dN a,-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AG OF2 CONTRACTOR APPLIES I"OR'BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, D as Owner/Authorized Agent
hereby eclare at the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Corte k 6X
Print Name
�z A /D' i--vo
Signature of 0 er/Agent 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 Rr X65
Frontage
Setbacks Front '�g' bl C
Side L: 21' R:- L: Zl R: 23
Rear
Building Height Zy. 2�-► _/
Bldg. Square Footage c�.� % -3. O
Open Space Footage % \
(Lot area minus bldg&paved
parking)
#of Parking Spaces 2„
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:
1d7 f Northampton
'J ng Department
OCT Main Street
Q 2000 :'Room 100
Northampton,
MA 01060
- phone 4!!J,58�.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: OWN
.a✓t.G.�C.� JAM 0106� ��ne � I � � ®�erte�I�Is#rl�
SECTION 2- PROPERTY,OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CAI A -Fn, �B SG�RI�I�I
Name(Print) Current g Addr ss:
Telephone
Signature 6 3 Sa'�
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIONI- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2� Oe0 (a)Building Permit Fee
2. Electrical , j;&O (b)Estimated Total Cost of
Construction from 6
3. Plumbing SuIIding,Perrnit Fee,
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 +3 +4+ 5) ZA Ob-0 Check Number ,
This Section For Official Use Only
Building Permit Number: Date Issued;
Sinature
Building Comm iss loner/Inspector of Buildings Date'
File#BP-2001-0353
APPLICANT/CONTACT PERSON FOX COREY
ADDRESS/PHONE 68 SHEFFIELD LANE (413)586-3550 Q
PROPERTY LOCATION 68 SHEFFIELD LANE
MAP 17C PARCEL 124 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT ADDITIONAL 4'X 18 TO EXISTING SUNROOM
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan `y
THE FOLLOWING 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 Commission Permit from CB Architecture Committee
Signa a of Build* fficial 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.
68 SHEFFIELD LANE BP-2001-0353
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 124 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:ADDITION BUILDING PERMIT
Permit# BP-2001-0353
Project# JS-2001-0575
Est.Cost: $29000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(scLft.): 25003.44 Owner: FOX COREY
Zoning: URB Applicant: FOX COREY
AT. 68 SHEFFIELD LANE
Applicant Address: Phone: Insurance:
68 SHEFFIELD LANE (413) 586-3550 ()
NORTHAMPTONMA01060 ISSUED ON:10 15100 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT ADDITIONAL 4' X 18 TO
EXISTING SUNROOM
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 1015100 0:00:00 312 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo