24C-130 SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 5 �� P 7 / U v
License Number
3 6 c-c-v i e 4_ .t. e/t,
Address Expir tion Date
z�-- s--gy —/z2 y
g re Telephone
9. ReaisteredHome Imorovernent Contractor: Not Applicable ❑
/
<'1p� D. ��r �0..�.9 -e^' et s01- 4-L f"aw -- / ` 7
com ny Name Registration Number
r 76 1 1 4/
A dress Expirat'on 7 Da e (
Telephone 5 lZ 2 Y
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 ❑
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding [p] Other [p]
Brief Description ofpjoped /,
Work: is (..f� �1"'"` V- C"At. J-c /0- i0a" -c C
Alteration of existing bedroom Yes !/ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. if New house and or addition to existing housing, complete the'followinq:
a. Use of building : One Family Two Family Other
b. Number of roo . in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square ootage of new c• struction. Dimensions
e. Number of stories?
f. Method of heating? _ Fireplaces or Woodstoves Number of each
g. Energy Conservation ' o ' pliance. Masscheck Energy Compliance form attached?
h. Type of construc .n
i. Is construct'. within 100 ft. of -tlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth • •asement or cellar floor b- ow finished grade
k. I building conform to the Building aiid 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
, as Owner of the subject
property / ��
hereby authorize �74-Ca ` "- , Vask -s5"
to act on my behalf, in all mat rs relative to work authorized by this building permit application.
4L
Signature of Owner Date
> / Z ? Cr'S , as Owner /Authorized
Agent here 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 N e
S' : t - of Owner /Agent Date
4, /
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 er been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 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 0 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav n, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
RE El ED City of Northampton Status c(Permit
l Building Department Curb'Cut/Driveway Permit Ammo — i 212 Main Street Sewer /Septic Availability . .�
III 1 avec Room 100 Water/ /Veil Availability .
orthampton, MA 01060 Two Sets of Structural Plans
DEPT. OF BUILDING INSPE •Yle 4'l 587 -1240 Fax 413- 587 -1272 Plot/Site Plans'
NORTHAMPTON, MA 0 • ;
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
2 C �} � % l�iL Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Addre s:
1 1 /1 1/(4/ 1 --(t/h4 V-- Telephone
Signature
2.2 Authorized Agent:
D. 1205 S' 34 e-4- � ✓ / /1‘11-7/ 1
Name rint) Current Mailing Address:
lJ - S 41— ( e2.tt
Signa e 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
2. Electrical 6r()-°' (b) Estimated Total Cost of
�,�i Construction from (6)
3. Plumbing G - Bu ilding Permit Fee
4. Mechanical (HVAC) _
5. Fire Protection � Syr
6. Total = (1 + 2 + 3 + 4 + 5) l 6 � l� • . c2 Check Number 3 L� Co G
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: 1 S191/ 2
Building Commissioner /Inspector of Buildings Date
24 WESTERN AVE BP- 2012 -0965
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 130 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0965
Project # JS- 2012 - 001680
Est. Cost: $16800.00
Fee: $1 00.80 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 4835.16 Owner: BISHOP MICHAEL
Zoning: URB(100)/ Applicant: STEPHEN D ROSS
AT: 24 WESTERN AVE
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584 -1224 () WC
N O RTHAM PTO N MA01060 ISSUED ON: 5/9/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE CLOSET & REMODEL BATH
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: Date Paid: Amount:
Building 5/9/2012 0:00:00 $100.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner