06-054 (4) 423 HAYDENVILLE RD BP-2003-0363
cis#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:06-054 CITY OF NORTHAMPTON
).ot-001
permit; Building
category: BUILDING PERMIT
Permit# BP-204$-0363
project# JS-2003.0602
Est.Cost:$6770.00
Fee:$2.5.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
se Group ROGER MARTINEAU 034750
Lot Sizefso.ft.): 128502,00 Owner: EWING LLOYD F&ANN MARIE DERE
7on1np:SR Apolicant: ROGER MARTINEAU
AT: 423 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
342 WEST RD (413) 562-8622
WESTFIELDMA010S5 ISSUED ON:10/7/02 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP, PLY & 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# Foundation:
• Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Ilenartment Fireplace/Chimney:
Rough: Oil: Insulation: �y�}
Final: Smoke: Final: OK /7"/p'o '
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON O
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/7/02 0:00:00 2633 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
•
•
Le . - 1J)., r
-. y of Northampton xi - -r *ata
ilding Department
•12 Main Street � ,a '<
�� I Room 100
�� OCT - 7 2002 • ampton, MA 01060 ; CTC, jtcSr.- 7Ft -'e` . -
' hone 4 3�5::7�1240 Fax 413587 1272 P
P � :fe z
V
C�• ':n4e a • I • CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed b 'cif;
s
1.1 Property Address. s' t T u Ctk ^x +
/ I 1 q Pim rwftiS .. {�
Zone -SOYerIay°y D.stvct ss'.+ Y *"a
7231Nay- 1u Rr�
L ekT{l Ohl (J l ew ill N CIO‘ D Elm St. District - CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LAa�a E(Print) og (A ac rr1 433 c u Lee�, N A
e Current Mailing Address:
��"" 12C (4I', -37)4 s a31
/y..i�+ il,ltL Telephone
Ca
gnature
2.2 Authorized Agent:
Pain kehh 1 tS
(,(P�antyyrI^1 ., Current M 'll�p�gticj54JC/
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
4769 PD
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 0% -3
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 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 DONT 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:
SECTIONS DEESCRIPTifON OF PROPOSED WORK(check,all applicable)
New House O Addition 0 Replacement Windows Alteration(s) 0 Roofing IB"'
Or Doors ❑
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: _ c - i.T. "Po.FJM 7,0 -__ , as/n/ 70 - - fa,.. /7wr-
30ya„9_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative U Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet❑
Ga",ifiNE ITh ' dtlttion=reRit iii0fnsing;compl"eteztlie.folloltiing:
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?
1. 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 ftof 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-'OWNER3AUTHORIZATION-TO.BE COMPLETED WHEN
OWNERS AGENT CONTRACTOR APPLIES FOR,.(BUILDING.PERMIT
1 L\oL\ , !F�� /
N 1,3 ) N tin h)K.lre- 't-e , as Owner of the subject property
hereby authorize .IEA � .( 'MGvv� —� �Q-��PGCL ��`1 S _to actor
behalf, in all matter lat(iv�e to work authorized by this building permit application.
Signature of Owner Date
IIIIIIIIIIIIIIIIIIIIII
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.
Print Name
Signature of Owner/Agent Date
SECTION'S—.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : A ,yede K$.4/ ,,4e ThVeAc1 _'C (;?'/760
License Number
35'2 w/457 lir{ 4.-",-47-E. / i/!a oio 8'3V"-3/ Zoo 3 ._
Address Expiration Date
Y/35G2 - SG2Z
,,Sig7 Levi Telephone
W11-i[ 31R-"iii ti r> -. Y TB . W; .. „x xm =Nk . x,p,.c:.... 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 0
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 he 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 3js,Nw, � `-\ �' ,t-27 � ��
p (ritg of Northampton �., e
gc,, )ale 'fit_,
s=S:' .:yrota „„ m
n� nu,
* _
DEPARTMENT OP BUD-DWG
WG INSPECTIONS L
212 Main Street e Municipal Building
Northampton, Mass. 01060 — `*
WORKER'S COMPENSATION INSi7RANLE AFB'IDAVIT
L j,-re e4,5,it 4.D1,-,40
{dcensee/petmittee)
with a principal place of business/residence at:
(phone#)
(ahzcltcity/stalehip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage For my
employees working on this job:
(lustivance Company) (Policy Number) ...,. (Expiration Date)
() I am 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) (Expiration Date)
(Name of Conu„cIor) (Insurance CompanyfPobcr Number) (Expiration Date)
(Name of Commactor) (Insurance Company/Policy Number) (Expintdon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
Ames azdifirml:bet irnornery to include information pertaining te an amuuon)
(4 I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
N011ei Okun tc even ten while hcmwwva,whoemploy Rtebneto do ganna>.wa,emSemeeo ce-repair work',en a SWliag Of
notmae Milt Ppmemit:in whichtie homeownermada am the pw>ne apntrt<nnnm.rete ea ort Gem"'1+Yaraitimcf m be
employ-me uMa'&wiener':ciimincentien AG(GLI52psi(5)).apptintioo by a bommwnz for a license or pmma mey miSvz the
Itgil nova Dien employe.imder the Wockee'e CompeosPion At
I umteritwd tin a Dopy el tee mtm.co:mey be f..uwde4 to Ne Depeonomet ufruhutrd A.ai4 x/Oran of ram,noce for the
wmage va5evim and thu Giltrst to sewn center upon;wxien 2$ANMeL 132 an ladto ti is c,...ti ce ofaiawui r 3cS
immgofe fort chip to 11.500.00mkC0.00 im �as met
(uuao of tip r}�=Icivilcmltita.pin the eh Stop work OTt aM a :;
caas _
Fad patwMaltue m7
, I Permit Number
I.. -”/JZ' .c. , e ' Magri_ ..—Lot# pL;
Si. ,'o£Lie•o . ermittcc s " m._.