35-013 (2) (�Itl) of �N ort I'lallip!Lill
J., K 5%a c 11115 r 5
LPAICI EN T OP U I I I)I'y(; I N S PE -I
I)
212 Main Street ' Municipal Duil(1111[�
Northampton, Mass. 01060
NVOFZ�KPAR'S C0-,'\,1-PETNSAT1ONi INSURANCY, AFFIDAVIT
C' ecl
0
v"I'th principal pl��.ce of busnesslresideucc at.
do lic!"h" c� :(1;!v, t;lz�,��l
the
d uct A r c 1_,S3q
tllc ";cvtrac�01-s ;.Sty'.. c-
(Npli'c of III
A
of
OV,
NO-1 I
of c11—4�luyx un,,'cr C:c
coN'c--'j;c wnfic--tioc r-:-,d tll--t fulur--to COVI-Img--under scc`c--2SA of M,('!,152 can Iced to tl�,
C—Itul ing of a filn-of up to S I of up to c -.i evil C.,in
(rte of SI1,.00 a ti.r 1 1 11s1 m-,
,t TIutntxa -
SECTION 8 -.CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ate'=r,r'x m„m?m p «aa .•rc ._ - `raa -cr t
9Re i tered.N e. ` , �<� _
Not Applicable ❑r ,
Company Name Registration Number
Address Expiration Date
tie 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 aff davit
will result in the denial of the issuance of the building permit.___
Signed Affidavit Attached Yes....... f/ No...... ❑
��'� �� ._ 'ry
1 .� tto Owner Exem fi'6n
The current exemption for"homeowners" was extended to include Owner-occupied Dwellinizs of one(1) or two(2) farniiies
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 wort: performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and up011
completion of the work fe-which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 _i.iability of Finploycrs to
Employees for injuries not resultin<- 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 7onin" 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
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ J
Brief Description of Proposed Work: ktAACf_ kV1W1)ews 19.002
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes `� No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a:"If New'h`ouse°and or"...ad iition'to existings housing, complete'<ahe:followin _
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
as Owner of the subject property
hereby authorize _ to ac; or
my behalf, in all matters relative to work authorize,' by th�s iuilding 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.
Print Name
Signature of Owner/Agent Date
J
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&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 `� 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. ArI there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location: __
City of Northampton Status o�Per tt;
Building Department CurbCt tID,`: w . �.a.
212 Main Street Se�erlS p rc a la :
Room 100 WaterlWeH,Avaf
Northampton, MA 01060 Two Sets�"of Str c a zFan`s
phone 413-587-1240 Fax 413-587-1272 IPot" iI Plans
Other-Soectfy s f
APPLICATION TO CONSTRUCT, ALTER, REPAffIj NVV f f�F(�LI�#i OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION JUN 2 J c"u0 ` 1
Tb s ction to be-completed by:office
1.1 Property Address: I OEFTtJr
BUILDING INSPECTIONS
.
PTON MA 01060`' Lo Unit
i 737 �,4lLMS /Zjj _
G�1�-L�dt Zone Overlay District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l . k'a�eclEX 7 3_.w � �eMS / ,erncnic�
Marne(Pri � � �r ent Address:
Signal ire
2.2 Authorized Agent.
Name(Print) ent %%ail ;; ,4ddress: -- ---- --- --
Signature
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant _
1. Bui!di lng Building Permit Fee
tirr-led Total Cost of
cns:!uction from 6) —
3. Plumbing Building Permit Fee
- - -- - - - 1- ------------ ------
__--
5. Fire Protection
6. Total = (l } 2 4 3 5) ,----- Check NGnnber This Section For Official Use Onl
Building Permit Number: Date Issued: --_ _-
S, i gn a t u re: ----------— -..—_
Building Commissioner;Inspector of
.a
. , . BP-2003-1196
GIs#: COMMONWEALTH OF MASSACHUSETTS
0 :3 =:t13 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-1196
Project# JS-2003-1859
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VALLEY HOME COMFORT INC 100061
Lot Size(sq. ft.): 15681.60 Owner: KORVEK ZIGMUND&KAREN
Zoning: SR Applicant: VALLEY HOME COMFORT INC
AT. 173 WEST FARMS RD
Applicant Address: Phone: Insurance:
20 WAREHOUSE ST (413) 781-0230 WC
SPRINGFIELDMA01118 ISSUED ON:6123103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS & DOOR
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• Receipt No: Date Paid: Check No: Amount:
Building 6/23/03 0:00:00 2377 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo