23D-171 (5) 34 RIVERSIDE DR BP-2000-1 1 78
GIS#: COMMONWEALTH OF MASSACHUSETTS
4ap:Block:23D- 171 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1178
Project# JS-2000-2062
Est.Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 10280.16 Owner: PUTNAM AMY&SHAWN HILL
Zoning:URB Applicant: PUTNAM AMY & SHAWN HILL
AT: 34 RIVERSIDE DR
Applicant Address: Phone: Insurance:
34 RIVERSIDE DR (413) 582-7947 ()
FLORENCEMA01062 ISSUED ON:6/23/00 0:00:00
TO PERFORM THE FOLLOWING WORK:ISHINGLE ROOF OVER EXISTING 1 LAYER &
REPAIR CLAPBOARD
DOST THIS CARD SO IT IS VISIBLE FROM THE STREET
nspector 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 6/23/00 0:00:00 662 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
t'
Ili _ersai'YA,d sY ,,rk'x ,'lepartment i,iSe'onlyx.' .::: ::
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availabil€ty
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
4 "?.1V SIDE BIZ Map )917 Lot / <` Unit
N GC M A OI O(0 2 Zone ��< `� Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Av11./ -Po-11v A► A % 4 Sz1VEIZS iDE D '. F!_orc- wct r- h
rint) Current Mailing Address: f O fo 2_Name
�� q i3 2 . �q 4�
` -- Telephone
Wignature
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 S'pp , q D b (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
v MD Check Number ,� 'c-) -
6. Total = (1 + 2 + 3 +4 + 5) � ' `� ��(j � /�-J, � 1,
This Section For Official Use Only
Building Permit Number: { 0U //7t? Date Issued:
0ignature:
Building Commissioner/Inspector of Buildings Date
I.
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 1/4 lC e
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:
I
. .
ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
iii
New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[b]' Other [ ]
Brief Description of Proposed Work: size 6 tkl N-)LE' vrot= , Q W94t t2.. 8 ("9741 NT C A.p to
Alteration of existing bedroom Yes r1 O Adding new bedroom Yes e,---No
Attached Narrative❑ Renovating unfinished basement Yes L"No
Plans Attached Roll ❑ - Sheet n
, '—'Vw house and or addition to<existing.housing, complete.;the foll..
a. Use of building : One Family ✓ Two Family Other
b. Number of rooms in each family unit: 2- 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?
• 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,_16 , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ,iA `( P(111\-) , 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.
i AO/ 1 -0,4/Jul
Print Name
avigr--k" G /023/cfr)
Signature of Owner/Agent Date
SECTION 8 - CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable 0
I Name of License Holder
License Number
Address Expiration Date
Signature Telephone
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 0 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,Stat d Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
',wok. . f
=.39-• lfnToti
A� s�414 E Crii 1 of
A ►� w �lc3enchnc((I
�' DEPARTMENT OP BUILDING INSPECTIONS �' — _1
212 Main Street ' Municipal Building `a,
Northampton, Mass. 01060 `''"
WORIOT,IZ'S CONQ'ENSATION •I1' SURA.N(:I, AFFIDAVIT
A-vi- P -
oi ccuscclpermi ttcc)
with a principal place of business/residence at:
4- 2..1V22StDE 1.) ►Z Fl.Dti2.e-Nee I•/,¢OIo6(fThonc') S$Z'
(sn-c..,t/ci ty/stalcla p)
• do hereby certify, under the pains and penalties of perjury, that
•
( ) I am an employer providing the following worker's compcnsadon coverage for lIly
employees worlang on this job.
•
(ura Comr_=m') (Policy Nu_ er) — (Expirtion 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 connensadon policies:
•
(Name of Co:ri:actor) (InRlranc; Company,ioUc,• Numbc;) (1=xDirauon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
•
(Name of Coai actor) • (Insurance Company/Po i • NttnbJ) (Expiration Date)
(Name of Contractor) (Insurance Comcany/Polcy Number) (Expiration Datr) .
(coach aciditiocsl ebod ifo< —,•to inctudr inforaaaaoo pertaining to an ecan-rDena)
( ) I am a sole proprietor and have no one worlang for me.
-•I atn.a home owner performing all the work myself
NOTE:pl-se be ew lrc that aa,t,Je bocnco.4vcr3 ubo employ pesoos to du e-.i.-r.-,r4r_,carm-.:caa+b c repair work on a dwdlani.of
on mote thin ibroc tmrs in aaincb the bocnoowocr rr,idce or on the puiireds appasrlrn_rn tbcro Lc Doc b�.,-.etly oomict-ni to be
cznployc-s ttnrlc the wui:rls m -,..11w A n(GLl52ss I(S))•application ation by a homeowvcr for:lip_or',null my eaidcnoc the
lc nJ atoms of co cnploy.<under ttso Worionec Compoccutioa Act_
1 I uodersiwd th.t a eta
copy of Ihi, tcmem may bo forwauded to Lb.Dep.razn �,t✓ ro
c d of Iniel Adcma'OQioo of L on000 for the
VC-L c vm[cntioo and t1Lt Eiltr to socurc oovctap;tinder socioo 25A of MOL 152 an Iced to the imvosIIioo of criminal penalties
°am:mi:sg of a floc of up to S 1.500.00 and✓or iinpri.loarnast of up to one year cod civil pmatio in tic focal ore. Work Order and e
fret of S100.00 a day a�im1 tX
For dsp.rtm=r.>:1 u.c Drily
.,./ ��r G� � �/ Permit Number
i` ,"•
fap:: Lot
Signature:of L sec/Pcrnuttcr 133te