31A-313 SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not App cable ❑
Name of License Holder
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License Number
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Address Expiration Date
Signature Telephone
— 23 7
9. Registered Home Improvement Contractor: 0 Not Applicable ❑
V )"Ki ISM EV / V 1c310
Company Name Registration Number
teg b s � b� / f\M A la /i ;
Address
Expiration Date
2-T7 � '
Telephone g.8 "
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 Q 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 buildinE 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 n Addition ( 1 Replacemerigndows Alteration(s) 1 1 Roofing
Accessory Bldg. 1 1 Demolition ❑ New Signs [0] Decks [Ea Siding [0] Other [0]
Brief Description of Proposed • e ' t (�i � �
Work: 1 �'�`' ° /i" V"
Alteration of existing bedroom Yes No Adding new bedroom Yes fro/
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, 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. Dimensi••
e. Number of stories?
f. Method of heating? F •laces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction _
i. Is construction within 100 ft. of we - ds? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or c- -r floor below finished grade
k. Will building c• - orm to the Building and Zoning regulations? Yes No .
I. Sep ank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
E A) SAO . ' 44 ' (/t ‘ p An/1 , as Owner of the subject
property � om
hereby authorize 1 f Q ' V 1 9 1 / \ W
to act on my behalf, in all matters relative to work authorized by this building permit application.
/ �-- Ste_. 24q/CS 5
Signatu of o wn e Date
W ki - c - A11/14 )4 � , as Owner Authorized
g ag ereby declare that the statements and information on the foregoing application are true and accurate, to the best o my now e•ge
• •e ief.
Signed under the pains and penalties of perjury.
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Print / 5 / / I / 3 1 /
- 7 2 , /l1
Signature of Owner /Agent Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
e•
Existing Proposed Required by Zoning
This column to be ` • in by
Building De.. ment
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 .:.ces
Fill
Anne & Location)
A. Has a Special Permit /Variance /Findin• ever been issued for /on the site?
NO 0 DON'T KNOW 0211 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document # '0. B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO N 'c.'X '
IF YES, describe size, type and location:
gr D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading e avation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
- City of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
rr�� -- 2013 j Room 100 Water /Well Availability
Fw No hampton, MA 01060 Two Sets of Structural Plans
�
13 87 -1240 Fax 413 - 587 -1272 Plot/Site Plans
1---°V t3U "SG l
p� fHAMProt -I, 01 C 060 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
bfil �o 14 Sr • Map Lot Unit
V ( Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
•
.SI S it) U4. t)/1 Vek Pi Cr jTh Pni-A-4Arrto I M
Name (Print) Current Mailing Address: // o / 3
• � Telephone
Signature -
2.2 Authorized Agent:
tifiiit• ConeA `II Alive Sr, 0(
Name (PC l -&-77 � / Current Mailing Address
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS j k Aet J {W 56 i•
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building t 0 (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
22
6. Total = (1 + 2 + 3 + 4 + 5) 4. j o { a � Check Number � `J� J Z/36-- This Section For Official Use Only `
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
129 VERNON ST BP- 2013 -0751
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 313 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2013 -0751
Project # JS- 2013- 001291
Est. Cost: $10388.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WRIGHT BUILDERS 84280
Lot Size(sq. ft.): 4660.92 Owner: SHILLIDAY SUSAN A
Zoning: URA(100)/ Applicant: WRIGHT BUILDERS
AT: 129 VERNON ST
Applicant Address: Phone: Insurance:
48 Bates St (413) 586 -8287 (116) Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:2/7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 2/7/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner