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17A-067 (3) �(11Aaf pT A e Gf TiQ Of g [76AChnscfta — w - — ca'� DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORICER'S CONITENSATION INSURANCE A < < AVIT r I, --------- vvith a principal place of business/residence at: (str�tici��/naic�zi p) do hereby certify, under the pains and penalties of perjury, dial ( ) I am an employer providing the followinu WOrkcl's coinpelisanon coverage for Illy eluplovees working on tills job: nna-anc� Con�r�.�- --- — --- -------- ------ - (rzpirtion Daze) (Polio N _m ubcr� ( ) I ant a sole proprietor, general contractor or homeo�.vner (cL�cle one) and have hired the contractors its c-d below who have the following worker's C,0Di) n-S?tlon policies_ (Name of Contr;cror) (Insurance Conlpan}';Polio Num�Y:) (Etiairaaoa Date) (Name of Contlacaor) (Insurance Conii)uv/PoLc-; (—HyDLrZuori Date) (?`Name of Contractor) (Franc Compan}iPolic N;nr_ �r) (Espirnon Date) (Name of Contractor) (Insurance Company/Polic NNumber) - (Expiration Date) (anach idditioc.il rl ifnoa�.,. y to inckic4 iaforu,L�oo pertaimng to nn ocotmc!'on) I am a sole proprietor and have no one work-jog for me. ( ) I am a home owner performing all the work myself. NOTE:ptc--s be awut that-Hilo hoar_o,w who,,:play pc:zom w do r- oac uciioa or repair work,co a d.cuing of oft moco than dace units is tcf"ch the homoo'n reuda oc oo the noun b appktrtcwa tb,- t a•c ooe gctxr�ooc=;ck cd to be etnploym under the w z?<cr s atim Arx(GLI52ss 1(5)),AWdcz 6crn try a homcoR-wr far a bccnx or permit may nldcace the legil of to of an amploycr under the Wokxe,Cocnpe Act l I-d�raLrnd chit a copy of this ct tm�=a,i,y bo f,-vnrd.od W tha pct=tmacat of Inlutrinl Acs&.&Offioo of Is_:u=snoo for the oova x6c vcrifiezlioo and tlat LiJ n e to aeutrc coverer undo s motion 25 of MG-]52 cw lend t o t he Laiposition of ai am-tl pen&Ibcs oomuct of a fine of up to S 1,500.00 and/or of up to one year and avi]pcaxttics in the form of a Stop Work or&=and a Lm o(5100.00 a day 1pz n- me For u, oily n.I� '� Pcrrntl l`llll:Dl?^S Lot rt Signature of Liccnse;' c nlittc,- e SECTION 8-'CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not,Applicable ❑ Name of License Holder: A16 2"A2 ��'[A y 01 Y l License Number Addres - / Expiration Date 6'dg Signature Telephone �• E) 3-- /o 9 d .....actor..' g m ; .. `„.. . Not Applicable ❑ Comb&i Name _ - Registra ion Number Address Expiration Date Telephone > 1 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...... ❑ Qwrieremptio 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 buildinE 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 applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0 Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other Q�] Brief Description of Proposed Work:-7,:�f+/' A&cf-,,f- )eebj J9 mew +6,-1eXi Alteration of existing bedroom Yes—X— No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement --Yes X No Plans Attached Roll ❑ - Sheet❑ 6a Ifi t ew ho a and oir ad°ditfbn toireirist'DW1641iri ;`cOMPIA e`Wfollawin: : 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 X as Owner of the subject property hereby authorize to act on my behalf, in all matter relatiyLto work authorized by this building permit application. Signature of Owner Date I , J,�, ( �� ✓C- 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 enalties of perjury. Pri t Na Signature of Owner/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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height / S 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 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 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 NoX- IF YES, describe size, type and location: T tj wR d �its ty of Northampton _�� 'Iding Department s =,. 12 Main Street C,1t��Fr1 Room 100 ;' ; dI!`orthampton, MA 01062 a tti. „pho-ne 41S-587-1240 Fax 413-587-1272 See �3 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-'SITE INFORMATION This section to be completedy off'ce 1.1 Property Address: . �� / Map, c) 2z—aa-z /1-I' l_t/_LZ/'p. Zone Overtay Dstr►ct FPM Elm 5t District �� CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: &1 66 Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: ,,, ` _ &vrea)Name(Print) ` Current Mailing Address: AAL�)- dv met`_6 2/Lq Signa ure 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 a "" This Section For Official Use Only Building Permit Number: q-7 -' Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 4 i ;.. +r � 999 t i' ' � ` S <t,+n BR-2000-0979 COMMONWEALTH OY MASSACHUSETTS M@pj k: 17A`-067 CITY OF NORTHAMPTON Permit: Bu�tdnrl Category: himnev rebuild BUILDING PERMIT Permit#. BP-2000-0,7 Project# JS-2000.1784 Est.Cost:$450.00 $25.0 PERMISSION IS HEREBY GRANTED°TO.- !COIL, Cantraqwrt�'. I License. Ilse Groin: Andrew church Lot&ZgL-a.ft.,): 22999..68 QLyner. BOYER WALLACE&ALICE&N(7RMAN Zoning:URA AgplAndrew Church `: 22 MPU,qAIINN S,�T & ntAddress: Phone: Insurance: 174 Spring, St (413) 586-U9I8 FLORENCEMA01062 .LP1©N:-W/nfl g: !#:gf T0PWRF ",TW .FI0LLOff'IN'O`WOjW- .REBUILD CHIMNEY TO ROOF, NEW BRICK & FLASH t PO T SO IS VI MORN THE STRE "T Inspector ol'Phreabing Inspector+ Wires Inspector of Buildings Underground: SerWee: Meter: Footings; Rough: Rough: House#'' Foundation: Final: Final: Rough Frame: Gas via _rt nt Fir�Chimney: t Rough: ©il Insulation E Final: Snke: Final: d k '16 THIS PERMIT NAY, BE REVOKED BY THE CITY OF ORTHAIWIPTON UPON VIOLATION OF ANY OF ITS R, S AND REGULATIONS. 9-ftfiC012 of Oc a anc s nature: ee imt, Recei t'No: ate Paid: C`e—ek N : Amount: Building 5141000:00:00 1659 $25.00 �r-Anth6ny