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29-160 (2) TO k Cr,tV of Nortllaillpfoll B - 6 �la�ertchn6rlta =_ '' __ DEP/tRTMENI OP BUILD0,IG INSPECTIONS — 212 Alain Street ' Municipal Building u Northampton, Nfars. 01060 WORTCER'S COMPENSATION INSURANCE A FMAVIT a AY 01 C-,t>_scrlpermi ttcc) %Vith a principal place of businesslresidencc at. _ -- ' G� -�� — -' r�/— %A e) (Phone- ) (stn. /c�,�/sZatciz�p) do hereby certif�:, under the pains and penalties of perjury, _hat ( 1 am an elllploVer pt-ovldln,�,, the f0110%vii i? woikcl's Compcns i)on ccivem—e for ink' cmplovccs wo1'..-ing oll this job �1T Rliduc t_OGlt ?IIV') (1'C11(7J Nu_ulxr) (L-,p.rztion 172tn) a sole pr-oonctoi, geilcial contl-actor or homeow-ne; (crcie one) and have lured the contractors listed below who have the follovtizng workel's co noen lion policies- (i lime of Con!-;cto.) (Innlrancc Conloan}vPclic, Nt rnlv:) (1=xpir-ann Dntc) (Name of Contractor) (Innlnnce Comuar,wPolic� Nurlc�r) (E\pirauon Date) (Name of Contracio,) (Insurance Com�an}�PoL Nn,r.Fx_r) (Expir:aion Date) --------- -- (Name of Contractor) Gn-wrance ComhaUy/Pohcy Numikr) (Expiration Date) (rfi-cll uSditicxul z'.xci if nccrury to rrxhx4 trLrixrlali oa pv to inutg to ill axtraCO��) (Lill ain a sole propnetor and have no one work-ing for me- ( ) I am a home owner performing all the work myself. NOTE:PI sc be aw-arc that vtuilo ooaic0,4 cn woo c:;Flay pc;iom to do mam cnxan cvni--.uiiou cr rtpair work on&dwtlyn&of rux-occ torn tbroc tn)U is which ax botnoowrcr rr=da oc on the QarrYf appurtcu it tbcan arc oo(&cxrally 000iidcmd to oc anplo)-rrs under thr korit' Act(GLI52Ss 1(5)).applies- ion by a oomcow-jcr far c 6cuxx oc permit may cvid-lcc the legal cts of an omployoc undar tho W"k-"Coen-pocuaLion Act I w-1 r�i.a d di t a copy of thii ct>L_j_y bo fotwn,lnd to tba Dc j_t.mt of li>dzi trial A_dcatY offioo of Ls_for tho covcntb-c vtxifreatioo aM taut f_ALrr to&cane covcntsc inkier soaion 2 5 A cf 1.tOL 152 can Icad to the impoai on of cr—n--d pcnaltica comir,i of a fine of tip to S 1,500.00 amvor inzrri}ooaxzII of up to one year end civil prnxhca in the form of a Stop Work Ordcr and a titer of S 100.00 a clay irailra me Fcx dc-;ia.:UW,;fid uic cnly Pcrnut Numtrr -- -- ------ -- -- x/V .C' C� 1�4:Ip:, Lot Sihn;thtrc of Licr tt:cc/F'cnilittcc. r _ s SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : -- License Number Address Expiration Date Signature Telephone " PP Not Applicable ❑ 9'Registered Home'xlmproyementiContractor 00a ,4/w- �4 Com an Name Registration Number S� iU ` "�✓ 5"-/S--61 Z-- Address Expiration Date Telephone [jjETION-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. " Hotfi 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 endows Alteration(s) ❑ Roofing ❑ Or Doors t Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work:T S-Jnf ( y 5)00e__S 1)Lre e y Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative iI Renovating unfinished basement Yes No Plans Attached Roll❑ - Sheet❑ 6a:If Nevi house and°'or ad"tlition/to e> fisting if`oMing COM0 eteftNe f011OWMA: 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, 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 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. Z44Y Print Name Signature of Owner/Agent 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&Localion 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 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 - r �1 AP of Northampton Q B ng Department 2 Blain Street om 100 -` +� amp'fon,• MA 01062 \ pho -1240 Fax 413-587-1272 of .- APPL CATI,QiQ-TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION 1.1 Pro pert Address: ;A This s ctionto be complete,c by offices '0 Lot% . " Unit u 9 r �^l W Zore �� Overlay DistrtcY' O Ehti St.Dtstrfct CB District SECTION 2!- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Addr ss: Telephone �--- `�_ 3 Signature 7 9— 7 2.2 Authorized Aeent: Y /��i T /t/ Name(Print) Current Mailing Address: ..�° v- &�-w Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a) Building Pe mit Fee 2. Electrical (b) Estimated lotal 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 ri fi ABET At 91 BRIERWOOO DR BP-2001-0472 CIS# COMMO +TWEALT OF MASSACHUSETTS Map:Block:29-160 CITY OF ORTHAMPTON Lot:-001 Permit: Building Category REPLACEMENT DOOR 13UILOINGPERMIT Permit# BP-2001-0472 Project# JS-20©1--0$03 Est,Cost:$1050.00 F 25.00 PERMISSION IS HEREBY GRANTED TO: Cont.Class: Contractor. License: Use Grout: Ed Corbett Jr 11 069 Lot Si sg.ft. : 14497.96 Owner. SANCTUARY DORIS L Zoning:URA Aaniicant: Ed Corbett Jr A T 91 BRIERWOOD DR AdicantAddress: Phone: Insurance 4 Reed Street (413) 584-6571 NORTHAMPTONMA01060 ISSUED ON:1113/00 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 REPLACEMENT DOORS 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: Finale Final: Rough Frame: ` Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation; Final: Smoke: Final: D/C /!-tit eye THIS PERMIT MAY BE REVO5WSipnatuit:NORT ANY OF ITS RULES AND REG Certificate of ccu anc Fee T e Recei t No: Date Paid:' Check No: Amount: Building 11/3/00 0:00:00 1 50 $25.00 212 Main Street,Phone(41 5 7-12ax: 413)587-1272 Building Commissioner- F ati> )