37-021 (4) 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 tf\1 0 C HAW ( e, '1 R,31 uD, or._ 04-i1 t
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 v 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 !/
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:
eFCTION 8—CONSTRUCTION SERVICES
,..1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: '1 OC" � � � U a 4 t( 9 fe
License Number
,S-6),we , - ()to G q/ d 2–
Address Expiration Date
Signature Telephone
k9 °Reglstered.Home Improvement Contractor: _ Not Applicable ❑
(3u =3 SIlcCe— . (
C o m p a n y Name Registration Number
`3C S� C� vYre c. (>-.s( is=-
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.
'gned Affidavit Attached Yes ❑ No ❑ C-LC) try t 1fi
otne,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
"CTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Q°I'Ll ?L12" 126V'M d wore' c.cr `fit tY`t STN f
Alteration of existing bedroom Yes C— 1 o Adding new bedroom Yes )4 No
Attached Narrative Li Renovating unfinished basement )4 Yes No
Plans Attached Roll ❑ . Sheetl>/'
Ne*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. 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
‘C t■ 1,-,0 Q( M I t - , as Owner of the subject property
hereby authorize a 0 C3 (-F C to act on
my be alf, in II-matters relative to work authorized by this building permit application.
l ijii- 211- c)-1
Sig at e of 0 ner Date
ECG V■A8-.1 , 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.
-igned under the pains and penalties of perjury.
4 t� Q-E G Vt J■44.4
Print Name
`Zl\(a2
Signature of Owner/Agent Date
•
Department"use only
City of Northampton Status of,Permit
Building Department Curb Cut/brlveway mt '
��1I-- s SXrg� r a £ Y �::: :d
09010 VW'N01�W�1a� " a n Street Sewer/Septicl,Avai1abihty �
SNOI1O3dSNI DN1011f18 301(130 oorn 100 Water/Well Avail k�l(ity � `� ,
Northa pto 1, MA 01060 Two Sets of Str +~fora FO �r ` � � �� r '
1;0,.r�e 41 87 0 Fax 413 587.1272 Plot/Site Plans t : . �? :z � .
(-1
t � z
Other Sped d r � �. x',a ��� ar3 �,
A' p •. . „ •+� -• " A ?ER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I WA J ;� t l -I
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/ ccy c LA)tic-am `CZ--W Map Lot Unit
6
at b62. Zone k " Overlay District
Elm St, District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
t,c l b`t��\t v1 l�'`!� 6`(t( -(-- k '4' ? 7
"'ame(Pri t) Current Mailing Addres 0 y�
I
Telephone
Signatu t
2.2 Authorized Agent:
V3 o Q a.,�cam.*ANA, 3 6 Sic ht utz-o L
Name(Print) Current Mailing Address:
er-kY-12-2-'7
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building 'S.D.., dui
(a) Building Permit Fee
2. Electrical (b) ms tar C
32-00 Esti Construction aed Total from (ost 6)of
3. Plumbing lo Building Permit Fee
o
4. Mechanical (HVAC)
5. Fire Protection .( IA uo //�
6. Total – (1 + 2+ 3 +4 + 5) 36► bud Check Number gj rr IW
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0673
APPLICANT/CONTACT PERSON Robert Reckman
ADDRESS/PHONE 36 Service Center (413)584-1224
PROPERTY LOCATION 644 FLORENCE RD
MAP 37 PARCEL 021 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �� `>,t
Fee Paid 0/
Typeof Typeof Construction: FINISH BASEMENT PLAYROOM/PRACTICE RM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 009498
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservatio i ommission Permit from CB Architecture Committee
� ! 2 � .06/
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
644 FLORENCE RD BP-2001-0673
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-021 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# i BP-2001-0673
Project# JS-2001-1219
Est.Cost: $38600.00
Fee: $160.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Reckman 009498
Lot Size(sq.ft.): 367646.40 Owner: LORIMIER KIM
Zoning: SR Applicant: Robert Reckman
AT: 644 FLORENCE RD
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:2/6/01 0:00:00
TO PERFORM THE FOLLOWING WORK:FI NI SH BASEMENT PLAYROOM/PRACTICE RM
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:y JdQ// House# Foundation:
Final: Final: 3�3�0/)91/143J
; Rough Frame:d z ,,
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:Ole( 3 •7. a G 14,i
Final: Smoke: Final: d Y 5/- /D-O 1
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy s signature: --/
Fee Type: _ Receipt No: Date Paid: Check No: ., Amount:
Building 2/6/01 0:00:00 9503 $160 00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
I