06-035 (3) 244-246 HAYDENVILLE RD BP-2004-0617
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:06-035 CITY OF NORTHAMPTON
Lot:-001
Permit Budding
Category: BUILDING PERMIT
Permit# BP-2004-0617
Project3S-2004-0868
Est.Cost:$2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Coast 045E Contractor: License:
Use Group Homeowner as Contractor_
Lot Size(sa,R.): 23435.28 Owner: GINGRAS LOUIS 1
Zoning:URA Applicant: GINGRAS LOUIS 3
Ae. 044 - 2 -_iAYi:%ENVI'r_
Applicant Address: Phone: Insurance:
246 HAYDENVILLE RD
LEEDSMA01053 ISSUED ON:11/19/03 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP &SHINGLE ROOF
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 VI Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: //��t
Final: Smoket Final: Ok '-j.aa -cm Q.+-w-w
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of OCCUCk3nLY �=� Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 11/19/03 0:00:00 445 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
•
City of Northampton ;sax,
Building Departmentcar+, , i rO+ir rt ki '41•1-
212
t•i212 Main Street t ina a
Room 100 rr (a Talai,,Nairaaaar,
Northampton, MA 01060 rx7 a fi aaaraafra. - crit: ri
phone 413.587"1240 Fax 413-5871272 - ' 1xY��x ._
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWEL-}NG
.. C ...
SECTION 1-SITE INFORMATION n
1.7 Property Addross. cq This 3?ctFot x oTkbeti0. eteQS y o i3ce oit
a- 94 - l` 1 HAYDEniv,:.ce 44 Map L p rt
itta,Pa 'Z3 R ,`, b
Lk kbs rt4• OI 0,5" 3 Zone' -...•-'5Eerfyy District .' v'
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LevrS r, c;-6.44s _ -'1y Hit' DEA.vn-LZ no L-Shos rA• o14-3
Name(Print) Current Mailing Address.
Ml3 - rite+ Titt C.St.e 5- 7;- A.477
�•.t, ,J'. r�^�w-• Telephone
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 permit applicant
1. Building �' (a) Building Permit Fee
J-i e=
2. Electr(cai - (b)Estimated Total Cost of
/1+o AYE' Construction from(6)
3. Plumbing /V&A/4 Building Permit F+ee
4. Mechanical(HVAC) "D/-
5. Fire Protection
6. Total =(1 + 2 + .3 + 4 + 5) 1,-) 000 Check Number
This Section For Official Use Only
BuiidingPermit'Number. Date Issued:
SignatdYe+
$u(l4ing Commtssipner/In>e-ctor of Bt d iggg _ (mat
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)
8 of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW X YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW X YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO >e 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 }e
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES
No X
IF YES, describe size, type and location:
TIOwN DSC P 10 fOF PROO5 :7W0 r *'k Ila he
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing Sir
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: S 14/P AA'd 46 SH, 'ye f-f G%QST. 4'6 /1.0014
Alteration of existing bedroom Yes / No Adding new bedroom Yes x No
Attached Narrative 0 Renovating unfinished basement Yes x No
Plans Attached Roll 0- Sheet❑
31UNee stfors-e andtorla lditibif ot""T Rigting HousinPacompreterthe>follol�%in .
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
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 QR'CONTRACTOR APPLIES=FOR BUILDING PERMIT
I, , as Owner of the subject prope
hereby authorize to a-
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Levi s :T. 6./`/61.4S , 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.
Low;) J. c;416445
Print Name
r/g, �,,,,Y,.-y II/11/0 3
Signature of Owner/Agent Date
0w
SEGpN.$.•iCONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
T ''.t-Brt'ana"•r:'�"rnen ' �"n`7ai •r 3's` t'iS=:f''ar ... srs: h` �+' .. Not Applicable 0
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 affic
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)famil.
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act
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 then
is,or is intended to be,a one or two family dwelling,attached or detached stnictures 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
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
Zoning Laws and State of Massachusetts General Laws Annotated.
•
Homeowner Signature
AA te.. nat
Ufifg of 3crfljamptnn I_ -*_*-
9t(j B {aaexrFinxlUe' f.'
9 =-- -
r
DEPARTMENT OA BUILDING INSPECTIONS (4 r Ie
2I2 Main Street ' Municipal Building
Northampton, Mass. OI060 —
WORKERS COMPENSATION INSURANCE AFFIDAVIT
E.
(liceusee/permintx;)
with a principal place of business/residence at:
(phonei)
(s[recUci ty/stateJxi p)
do hereby certify, under the pains and penalties of perpuy, that:
t ) I am an employer providing the following worker's compeussston coverage For try
employees working on this job:
' (`-.prance Company) (Poicr Number) (E::pimrion Data)
() I em a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (ExpLmtioa Date)
(Name of Contractor) (Insuranw ComnaiwRohey Number) (Fxptratiou Date)
(Name of Contractor) (Endurant Company/Policy Numbed (Pxpuadon Date)
(Name of Contractor) (Insurance Company/10E0y Number) (Expiation Date)
(eaxi u4.51. nitete if n..-...y to ixhuk iafttmatim peerdssg to oil emendate)
() I am a sole proprietor and have no one workdng for me.
1§.Q, I am a home owner performing all the work myself
NOTE:pt"`"be awre4s while hOOCOWlacts aha employ pmmem to A+n o.-ewe+or ma;‘v.vcoe a dveliiog Of
ao [ACM thin thmounit.ia retie]]the M,mnvv rade ec on the croureb smut<cmt lhe+o me wt ceremony comideml to be
cni loyca mace the vn rkeel ompazt4m Act(GLI51 I(5)).tW n woo by a homcoam fm a lic,c Cr pamil WZY evi•_ 't tLe
legal cisme of an employee under Me Waimea Campeoeniem net
emien ad CM%cpy ofDit tlrmexa may be foawadiod to the Dowwart of heamoiel na*.*r ot£oe of LAWS=£«to
cvvenge vaifiaiev podIltet failure to wart wlteago arts section 25A oIMOL 152 on Ind to the inwosiSoa of cranial!pe5 ilia
emialea ors fine otup to sr}00.00 meter�n meat of up to cm t ®
a4cva pF'u in def Som of a wok Ott sod a ..
Ear oraloo.00 a day ageing MC.
Fm dtp^*m>Y'l use only.
//JJ pe Permit Number
....: ("'B-crmiuee //NC 3 Mart Lot a'
Signature of Licamvr/Permitlec Late