17C-184 (6) a 6r1 1) of art 11alIIp o I I
6 1155 AC fill 6(t
1)1:1F�RTl�Ll ) 01' BUILDING IN.SII-( 11 1.S
212 Main Street ' Municipal Buildinj, —
Northampton, Mass. 01060
WORT ET'S COMTENT SA`I'ION INSURANC)" ,tl+'FIDAVIT
�;-ith �. principal place of businesslresidel�ee at
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I undc:auid Xc may 1 o f01�i',—I{ j to tiio U<tK.r tnr,i:of Iixiilstn�l Ac�i��'n'i Ofliro of I:.:,.0 u>_c for lim
covcn;c vC T1C d tt t fail c to s trc bvrtabo ur r cc icn 25A cd` O1,152 can Ic_d to t1x im1»zaian c; ::i�l�, In Oani tmg of a lv to S 1.: J.!�J nay'cX ir::Ilris�yvnk:,of up to on.}ra:r.�j civil lxiul!icl in:;�t al.,o(a
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SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ��`.rl�1�� �, �tiTT __ _ G-`�- C9.7L i w
License Number
ILI
Address C•\' �a� Expiration ate
Si nature Telephone
Reitered`Nornef�rriprov �� ��� ' Not Applicable ❑
Company Narne Registration Number
Address Expirati n Date
YV\.YAI fit 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...... ❑
11� I0 0 l-B0x e §40ri
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)faniiiies
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 borne in a (wo-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 buildino permit.
As acting Construction Supervisor your presence on the jot) site will he required from time to tune, during and upon
completion of the work fCr which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Lmployees 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' DE SCRIPTION;OF PRO POSED.WORK-(check allsapalicable V% "Iu
New House ❑ Addition ❑ Replacemen indo
Alteration ❑ Roof g
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs Siding Other [ ]
Brief Description of Proposed Work: tom' `-SVt�+ .i1! �
i1..,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes i,_No
Plans Attached Roll ❑ - Sheet❑
6a. 1f=New hduse,'and'.or.'addition to`existin�Choiising, complete=tlie';followin;r:
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
---ee,, C Z �S' as Owner of the subject property
hereby authorize _ �t`i k-L iIN M to ac..; or
my behalf, in all matters relative to work authorized by this building permit �pplicatinn.
Signature of Owner Date
2ff —i.a -- ----- --_---, as Owner%Authorized Agent
hereby declare te state ents 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.
C' k{ c 13 -� ---------- - - -------
Print Name
Signature of Owner/Agen Da e
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,ffoor/on the site?
NO DON'T KNOW YES _V Q,--EP
IF YES, date issued:---A-'NW -;.m
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES !/ 9Z
IF YES: enter Book _ ��- Page ?�j _ and/or Document #
B. Does the site c:'.)ntain a brook, body of water or wetlands? NO _ V/ GON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservat on 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. Aref there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location: _ _
XQQ
City of Northampton S atusv Per t
r
Bil'din Department CurbCuf/,D vv , e
212 Main Street S rZSeptcA eb `
Room 100 Wa erlWe l Avaua,wi}r U '+� '
y� a ,gar .''$
�Y mpton, ''MA 01060 Two Sets offStr e ttra a�i
p Fax 413-587-1272 Pl %Slte Plans
�d?ie A-587-1240
Other Specify � � T
.Y.,,
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Proms Address: �This section to be completed,by,office
Map F fe Lot Unit
Zone Overlay.District
EIm St. District CS District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) C:rrert M-it na Address
— �-- �– -- e,ephone -
Signature — —
2.2 Authorized Agent:
Name(Print) Current tvlaihng Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item stimated Cost (Dollars) to be Official Use Only
completed bvermit applicant _
1. Building (a) Building Permit Fee
!b timated Total Cost of
Construction from b
3. Plumbing Building Permit Fee
j .+- Mechanical (f-IJf'.r�;
5. Fire Protection I
6. Total = (I , 2 3 + 4 Number
ThisSeglion For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings. Date
File#BP-2003-0998
APPLICANT/CONTACT PERSON WILLIAM PICHETTE
ADDRESS/PHONE P O BOX 454 (413)628-4787
PROPERTY LOCATION 53 CHESTNUT ST
MAP 17C PARCEL 184 001 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: RESUPPORT EXISTING PORCHES NEW FLOORING REPLACEMENT WINDOWS&
SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 071053
3 sets of Plans/Plot Plan
THE FgKILOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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
Permit from Ehn Street Co ssion
"�_/wx 1.20e2
Signature of Building Official Date x 11
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
BP-2003-0998
GIs#: COMMONWEALTH OF MASSACHUSETTS
.� '`
CITY OF NORTHAMPTON
Lot: -001
Permit: Buiidim
Category: BUILDING PERMIT
Permit# BP-2003-0998
Project# JS-2003-1598
Est. Cost: $30000.00
Fee: $150.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WILLIAM PICHETTE 071053
Lot Size(sg. ft.): 9016.92 Owner: BOULEY ERIC S&MICHELLE
Zoning:URB Applicant: WILLIAM PICHETTE
AT: 53 CHESTNUT ST
Applicant Address: Phone: Insurance:
P 0 BOX 454 (413) 628-4787
ASHFIELDMA01330 ISSUED ON.5 115103 0:00:00
TO PERFORM THE FOLLOWING WORK:RESUPPORT EXISTING PORCHES, NEW
FLOORING, REPLACEMENT WINDOWS & SIDING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/15/03 0:00:00 1412 $150.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo