23D-091 (3) 171 FEDERAL ST BP-2001-0994
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-091 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0994
Project# JS-2001-1788
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ronald Mistarka 118693
Lot Size(sq. ft.): 23609.52 Owner: BYROM HENRY G&RITA A
Zoning: URB Applicant: Ronald Mistarka
AT: 171 FEDERAL ST
Applicant Address: Phone: Insurance:
P 0 Box 205 (413) 584-5140
NORTHAMPTONMA01061 ISSUED ON:6/4/01 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & 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 6/4/01 0:00:00 800 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability_ ____
Room 100 Water/Well 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
1.1 Property Address: This section to be completed by office
/ ea ef,/ki r ,I Map Lot Unit
r,/U I k7. / Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
, , C . cl, Po , /7/ -Q4 ef/fi
Name(P int) � Curre ling Address:
�lGv. U/O(0 2--
Telephone
ignature cS7�Q-39 2-
2.2 Auth ized 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 r--
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
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 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 l
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 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing d„.--
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 61-0 r�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement _Yes No
Plans Attached Roll ❑ • Sheet❑
Oa, I � +ru� �" !tlitfo Y-` ghousing, complete the following:
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, / A../ , as Owner of the subject property
hereby authorize leo/kJ /€f/4 i-Ai4 to act on
my behalf, i all matteative ork authorized by this building per it ap lication.
Signature of 0 Date
, 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 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: &fig 6'7/ 5 .&(71 �-, 9‘ ( �..3
/� } A / License Number
//-✓\ ` �� I v y r f //d G'/_
Address Expiration Date
c4 /24/t — "1c/
Signature Telephone
1- at Itt Not Applicable 0
rf & (o / �� it' s' 3
Company Name Registration Number
tt 71—/ 0°_3
ddress Expiration Date
Telephone S 77
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 0 No AlQ
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
•
0 tt/0-f p,.
• °ti (rift of Northampton
I.
Vii/,tr f145sncltncctla'
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
•
Northampton, Mass. 010G0
WORKER'S COMPENSATION INSURANCE AFI"D)AVIT
•
(li ccuscdpermi ttec)
with a principal place of business/residet(cc al:
(phone:')
(sar-f/city/stale zip)
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 worlOng on 11is job.
(lnsur;nt~ Company) • (Polio:Nu abcr) (r —pinion Dale)
( ) I am a sole proprietor, general contractor or homeowner (cifce one) and have hired
the contractors listed below who have the following worker's compensadon policies:
(Name of Co tractor) (insurance Company/ 0UC{ Num:cC:1 (-rlirdtionDate)•
(Name of Coo tractor) (lns-,uancc Company Po!icy Nurncrr) (Ex-pir:i on Date)
•
(Name of Conn-acto,) (Insurance Company/Policy Number) (Expiration Date)
(Name of Coatz-actor) (Iilsurarncv Company/Policy Number) (Expiration Data)
(ettada ab iocil r'.uci ifn....—s.ry to,nduck inform...00 pctaining to.n ooa>acon)
^Lam a sole proprietor and have no one worfdng for me.
( ) I am.a home owner performing all the work myself.
•
NOTE:p-icz cc be ea-uc the.Mt.Ijo�0C0cc0WOCCT3 wbo� c iploy�lpG ctai._t1o_lSJ n-n NlY coo a rcpau Wort oo.d.•<i ing of
ont moon tb-cm tam vc=it,in ll�cb'be bomoor oc R71U0 oc OO thn g)ouodi appurtcnara tb o LT we ccxrnAy oeer:d&cd o be
cci ployct t,rV the v.-cc-keel ocrpcsatioo Act(GL152sa 1(5)),npplitation by•bomooa' for:Anna":oc permit to:y cvidcooc the
Iegil rtanu of an ex9loy -under tho Wock.olr Cocopomaiioa Ad_
I uodustaad theta Dopy of this etatemmt may be forwarded to tbo Dopsrtmast of lndutrid Aradec 'Olrloo of Irwrrooa for the
°Overige verification and tlt_t f-dime to'Deane boverage under souioa 25 A of MOL 152 can lcsd w the imposition of criminal pcnsltics
oomisting of■floc of up to S 1)00.00.nd/or imprisocancc1 of up to occ year end civil pciutio io the form of.Stop Work Ordrr and a
fino of 5100.00 s thy.print me
For dep.rtm —s..l use only
Permit Number
lviapg Lot t
lgnatun:of Li crmiucc e .1