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11C-026 (3) :(j fp, .0 1 (�'Ttlj of .... ..... DEPARTVL-:N`r OP 13UII1D.r7'G INSPECI-IONS 212 Main Street * AJujjicipal Building Northampton, Mass. 01060 WORICEIZ1,S COj,4TENSjknON [NSU-RA-NCE k , , AVI T v,11ith a principal place of bUs1'UP-S&/FeSIdenc'c at ——------------ do hereby certify, under the p,--irLs and penalties of perjury, hat I am ail employer providing the foIlo\viniz coverage for my C111(flovcCS \vol�-Jlw on this 'oh. (111sur2lic- am a Sole proprietor, gcrtci-,ll contractor or hojjjco«-nc.- (circle one) and have hired the contractors listcd below who have the f'OU,-.)VYU' p' workers C")E-]Dtnsaton pokes: (INa-mc of conl T-zic-'01r) Oasurancc Compmy/liotic-, (E-xpij-,iuon Datc) (N'amc of COL)-T"C-,Or) On-qir-ancc CoTjmaiv/PotIc-,, Nwijcrr) (—Expu-noon Date) (Naive of coaLnlc-io;) (In�-U=cc cornpa11)/-Pokc:-'• (-ExpLmuon Date) (Name of Conti-actor) --(Insurance: Compaiy/Poldicy (E\pLi-ancia Date) to all Ln a sole pi-opnctoi- and have no one wor!drig for me, a-in a home owner perfo=' ,, all the work mysdf. NOTE:please be AW-41-C d1z-'IAIO h'xr'cuwncn wtx)cmplcy mom to c3o rjzt•�,qcr v r^ oa cr rupw wo&-co L dl'eJL129 of --(.r dL-11 Orc-0='d to wlincb LLc Scnnc.,0-TYCr rr-lid'n(X cxI th't UrOU13'j,appurtenirl tj)'='to arc m-,(&cn<mlly ocK-z:ckrcd Lo be -IVIOY-urxt'r the Ac,(GLI52,z 1(5)�af-vtic3.6cm by a hoc co°A-=for a kcax 0(po-ru?-Y cll�x the O-In-of an-=Ployx uudor d�' Wokc'-Coc�pcm.iion Act, u-:crct�id diji a copy of this asLa—i o y be fcvcied to tbo D':T-,_oj of L_j_': j Ar d-&Of of ln�+z°`»for Lbn cov"Et vcrlfi=iOc a-ld Lhat fA- L-"c W ta,d-&oction 25 A of N(Gl-152 can[.,A to Lb.=po-ti-of-m--11 P-il - co-L54-L-tg of a 6DC of up to S 1.500-00 and/ff i:1{rnooriX11 of up to ore Yn,j&,-.d cj-'-d pc,,.I-jc,in d)c form of a s1cp Work Order a-'Id rim a(S I DO.00 a d Y icsui�cc Foe"I&7- �l Ux only U p CTMI(N Um L-T 0 Sir",WIFIC of I.iccii--,ccjjIcr-;mttcr-. SECTION 8-CONSTRUCTION SERVICES j 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9 Registered Home tm�ra 'eriienfi'Contractor �_, ,,. ...w r ,, , „# 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 ❑ 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 buildiny, 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 SECTION 5- DESCRIPTION OF PROPOSED WORK(check all��cable3 New House ❑ Addition ❑ Replacement endows Alterations) ❑ Roofing Or Doors Accessory Bldg. ❑ DemolitionD New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work:—LLV-5_YV//,}7. iac-f— 0"1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll D- Sheet❑ 6a:t lfNew-;house=.a�t� ar?aticli�ii�r� #o�zist�ri�, hoi'san.�:`cO�plet�'t1 � fiOEt®w�iri�: 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? h. 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, 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 RON!111i 11; ,rs R I, I.111// ~1 , 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. Signed under the pains and penalties of perjury.. / (�" 'e,-n�— Print Name ' Pa Signature of Owner/Agent Date Section 4. ALL INFORMATION MUST ]BE COMPLETED, or PERMIT CAN BE DENIED DUE To LACK OF MORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size V Frontage Setbacks Front Side L: R:- L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bid;&paved arking #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: Yt__. Ar^a YC f2*�A F�TL*pVL:L t� U•USeU 6t� E, k A'C K am e0 a a �x 3 far3 > �y City of Northampton � � � F� Building Department ors t Pe rrm � 212 Main Street Room 100 ru��r(abrik� , Northampton, MA 01062 ``���"`� p Tsro�'StricturJaS � � �us' `at6 hone 41 587 1240 Fax 41 7 '` r x p F 3587.12 2 Pct/sit Pans ,,,x, �4"M ; ' i , Y ,tx•:• ,u, Y1` C\ to ,aw�.z? ,u �i' �"c, '`� .z � APPLICATION TO CONSTRUCT, ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION`1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map':. Lot Unit Zone ' — – Overiay,Destrsct'' EIS St District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1,Owner of Record: Name(Pri t) Current Mailing Address: Telephone " 7 Signature 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 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 =G + 2 + 3 +4 + 5) �' Check Number This Section For Official Use Only Building Permit Number: R-R3y Date issued:' Signature: Building Commissioner/inspector of Buildings Date a �w F 4 STOWELL ST BP-2000-0994 GIS#: COMMONWEALTH OF MASSACHUSETTS M :apBlock:I IC-026 CITY OF NORTHAMPTON Lot:-001 Permit: BUildinQ CA=ory:Loo ng BUILDIN G PERMIT Permit# BP-2000-0994 Project#; JS-2000-1815 Est.Cost:-$, 775.00 Fee: 25.0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Ed Corbett Jr 116069 Lot Sites$.ft.): 8494.20 L9wner TIC PlG ELE M ' Zoaang:URA ..,. Apr't ;: Ed f orbett Jr AT 4 STOWELL ST AAnlicCWAAd'dress: Phone: Insurance: 4 ReedL Street (413 5) 86-5192 NORTHAM PTONMA01 060 ISSUED ON:5191010:00:00 TO PERFORM 7WE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & RUBBER ROOF ON REAR DORMERS POST THIS CARD SO ITIS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring B.P.W. Inspector of Buildings Underground: Service: Meter: Footings:. Rough: Rough: House# Foundation: Final: Final: Rough Frame; Gas Fire Department Fireplace/Chimney: Final: Smoke: Final• O�, S- 2mc0 THIS PERMIT MAX BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLATION F ANY OF ITS RULES AND REGULATIONS.,, Certificate of Occu2anc � signature: Fee Type: Receipt No: bate Paid: Check No: Amount: Building 5/9/00 0:00:00 3525 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo