17A-239 (2) Oak Fro� ��-� (j,if�) of
A .. � `?�R36 A(I11IL(I10
DEPARTMEIJT OP BUILDf\1C INSPECTION'S -
212 Main Street ' Municipal Building /.
Northampton, Mars. 01060
WOJ IRE Z'S COMPENSATION LNSURANCE AFI`UMVIT
�;�u�p�nnitte�>
with a pi-Mciplal place of businesslresideenccc at
`---- �G2 1i�1`G
(SLT1 welt}'Ma1G173p)
do hereby certffy, under the pains "I'd pcil lties Of perjury, :h t
( ) I am an employer providin- the followinu workcl-'s conm(e!IS non coverage to Inv
clnplovices wolfing on this job
--- (Instinrn� Comp:n.') - (PcGc;Nur,�ir_r) (L-�;piruor, Dat^)
( ) I am a sole proprietor, general contractor or homeov�rner (clfcle one) and have hired
the conuactors listed below who have the following wort:et's c000ensatjon pohcles:
- (Name 01 con! CL07) -- (l I1RIr311G �,Olilp2l}'i GUC'! T' S7;i? ) (L'?:;1:7P.1i0i? ?lC)
(Name of ContTactor) (Lnsurancc Coma_wvPohc v (Evoir,:tion bate)
(Name of Coairacior) (Insura_nce Compan)' Poh:q N:Im r) (E\piracion Date)
(Name of Contractor) (Insurance Com;,H]] '/Policy NUmIKI) (Expiration Date)
(cnadt dd oai z xc a nccaur;to Incu n oZ a.ioc pain' well ooa ago- )
( am a sole proprietor and have no one wor�mtg for me
O I am a home owner performing all the wort; myself
NOTE.plc be a 1Ic flue 'Ll.txur niv rs 11�3 caTp[Cy p rom w c.) cr r pau
rec axxc tL:n ti roo tmi'�in which ttx lw:t h.ms rcvdo a oa tfv fTo'-�=�zYpuri<: tbcc',D�c rr:�C�cxrnlly occsid:rcd tv be
cnx)loyv--�ury'Scr dtc ccuap=ntlm/,ti(GL152r-,1(S)�c{ Licz_13c-n b-f e fm c lica2x«perTMI cn.y c'Kd Co tj1
Icgil ctnnu of en omplovor under din Wort cet C�oc Lyoo AEC
f undcrstind dut>oopy olthii ciatanml—y bo fO,-O d.od W t}-Dcjn im i of Ir fiis id Ofro of lanai for dx
Cowl Fc vcrilolion annd tttt f_ihuic t4&CCIUC co"nusc antic zo on 2 SA of MOL 151 can Iczd to tx OQ of crunm.]pc¢a11ic
cocniutiM of R fine of up W S 1,500 00 andW ci nicxirzr-ri of up to rnx}TS tae evil Lq L�r_r(xm of a stop Work Otdcs rind o
fim of S 100.00 R day RFalmi ar_
f or c:r; ivY�l t�c only
(
S11, afltm of L,[ccnscrlYcrliuUcc -tl e
SECTION'S-CONSTRUCTION SERVICES
"'` .1 Licensed Construction Supervisor: I� Not Applicable ❑
Name of License Holder : 4(� 00 d
License Number
Add ss` Expirati n D e
T$41 �- ISO
Signat a Telephone
\
Not Applicable ❑
/ 0394' `
Company Name Registration Number
Fd
Address (( ` / Expirati n D to
�Ty ��-�— ( Telephone l9'0 5 U
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....... Cl,� 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
ECTI SRI TC DN OF PROPOSED WORK(check all app]icabl
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: sr-1-p—t J� 0 L-h Q o o;a
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
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?
. 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, I`. 'l C_ L'_& kfke:e as Owner of the subject property
hereb authorize limit_ X71 �-ll� to act on
my eh If n all tters relative to work authorized by this building permit application.
Sign ure f Owner Date
as Owner Authorized g
hereby declare that the statements and information on the foregoing application are true and accurate, to e"best-of my
knowledge and belief.
Signed under the pains and penalties of perjury.
it
Print Name 11A/
1
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
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 I/ 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:
e
rti
City of Northampton \ ;;
00 kk Building Department s
212 Main Street y
Room 100 rl twf
Northampton, MA 01060 t�
phone 413.587.1240 Fax 413-587-1272 \
f
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 comple#, b
C. CA i'\ Map Lot Vnit
b2T�� 77QJ /P14- Zone � Overfav District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: I
Name ri t) Current Mailing Address:
Telephone `s
Sign e
2.2 Authorized Agent: r
0 A y (0 t—y 2.i apl& 2 l It[JILT L ST.
Name(Pri 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 Poo F::: 2 �� �G (a) Building Permit Fee
2. Electrical (b) Estimated Total Cast of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+5) d, Q G Check (Number
This Section For Official Use Only
Building Permit Number:,_ 204-_ Date Issued:
Signature.
Building Commissioner/Inspector of Buildings Date
t
61 LAKE ST BP-2000-1036
GIs#: COMMONWEALTH OF MASSACHUSETTS
aQBlock: 17A-239 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1036
Project JS-2000-1868
Est.Cost: $7200.00
Fee: $25.00 PERMISSION IS HEREB Y GRANTED TO:
Const.Class: Contractor: License:
Use Group: David Fortier 103999
Lot Size(sq.ft.): 24001 .56 Owner: WARNER ERIK
Zoning.URB Applicant: David Fortier
AT: 61 LAKE ST
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965
NORTHAMPTONMA01060 ISSUED ON.5 117100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, 1/2" PLY & SHINGLE ROOF
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 5/17/00 0:00:00 3238 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo