23D-091 (2) ,
171 FEDERAL ST BP-2004-0287
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-091 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0287
Project# JS-2004-0428
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Punska 100795
Lot Size(sq. ft.): 23609.52 Owner: BYROM HENRY G&RITA A
Zoning: URB Applicant: John Punska
AT: 171 FEDERAL ST
Applicant Address: Phone: Insurance:
5 Dimock St (413) 584-5533
LEEDSMA01053 ISSUED ON:9/17/03 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH 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 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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 9/17/03 0:00:00 361 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department dse only ``
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability,
Room 100 Water/Nell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify___
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
1-1 1 f i J� Map Lot Unit
l i C
STkie-- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
eti t5 fcml 1')I ST i3/�st c'o ,
Name ring Current Mailing Address: g
Telephone !�y L/ S5
Signature /15734 —
2.2 Authori d gent•
�o h,, s kq b wv-k. ST LaDds 014-Nos3
Name(Pri Current Mailing Address:
IAi y—tcc 3,.Signatu Telephone
itySECTIO 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building Qp0Y�S ! Ott)* CV (a) Building Permit Fee
2. Electrical I.
(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 , ry "
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
DENTED 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 V 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:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Q'
Or Doors ❑
Accessory Bldg. ❑ Demolition[❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: CO 4 lM Cirk SY)40.12 C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
sa<'If New.huse`"o aril Or.-addition to'exi u`sting-hosing, complete the'fo gllowin
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 4eu,5jtryt'arf\ , as Owner of the subject property
hereby authorize v.),( h Ci:::)C AAS kA to act on
my behalf, in all tters relative to work authorized by this building permit application.
_.� ? 1 I'7 Io
Signature of Owner '- Date
I, il)h A WA KSt , 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 enalties of perjury.
Print Name Z /f'7/o
Signature of Ow er/A ent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : 1—CAlVk VA.vs kft v J
License Number
Address Expiration Date
Signature Telephone
9. Re iste d Home`Irh rovement Contractor F � �, �l0r, mNot Applicable 0
Company Name Registration Number
/oyAddress Expiration Da e
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 th ilding permit.
Signed Affidavit Attached Yes No 0
11. — Home Owner Exemption
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 _
. . , .
4
4�t p1. qiii, of h
8 tt.
B�Y 0y�l� 6 Alassacttnsctts' ''=! '_
-cc,-fir DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 No'��.
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, ` vkNAPrs/ii-
(li censeeipermi ttee)
with a principal place of business/residence at:
()rock_ S'T-_ _ m 3
S. rYlii- (phone#) sG If-5 S 3 J
(bttc t/city/stateMp)
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:
- (Insurance 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)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional if n <•ry to include information pertaining to all coatrnctora)
( 'I am a sole proprietor and have no one workdng for me.
( ) I am a home owner performing all the work myself.
NOTE:picxise be aware that whim homcov.9as who employ persons to do arch tenLnn construction or repair work on a dwelling of
not more than throe units in strict the homeowner resides or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's compensation Act(GL152,s3 1(5)),application by a homeowner for a license oc permit may evidence the
legal status of an employer under the Worker's Compoosation AcL
I understand that a copy of this ctat:mart may be forwarded to the Department of Industrial Accidents Office of Imurwoo for the
coverage verification and that failure to secure coverago under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S 1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
firm of S1oo.o0 a day against me.
For departmental use only
Permit Number
1 ;2 M•aP __Lot#
Signor of Li t
t - censcelPermittce o
— �� is