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29-070 Crzf of �vTn uf(jaillpfoil � ,. E Aiasenchntrtls DEPARTMEIJT OF L'UILDR\IG INSPECTIONS 212 Alain Street ' Municipal Building Northampton, Mass- 01060 W01I 1Q-IZ'S CONII'I;NSA-MN MSURANCE� AhFIIDA VIT -- (]i�usc:Jpernl)ttcx) ,th z plincipal placr. Of bUSintSS/reSldcI)cc at C9l v,S - -- ,in.-Uo�y�_/�D___i6i-G�v�� S✓ ��� (;hone- < (sr��/aty�naic_��p) do hereby certify, under the pain-S and penalties Of perjury, Thal ( ) I atll an empio, providin: the iOliew"11w. worker's Con for In%, elnpio,,cc� woi�:ins; Jan this jnh ( su1 n corgi-. E v) 1 Lail c SOIe prODilCtOi CIeilcr<_i GOP,LT-aCIO" Or 1!On1C0'ti'ilei �C Clc OP_e) a-Do h v(V lIjjtd the com—,actors bcjov,' who hove Clle "VOF'::C;S Ca 7 e17S2U0r! pC�JCIeS (i ::mc of Co;!. D�d - (N=ie of Couliac;or) OjLsuranc,� F'cirauon Date) (N=e of c0='!clor) (Insuranc Compare).1PoLc) Number)- Dalc) (Name of Conti-ac-Of) (Insurance Compa y/Policy Number) (E.wlmuon Date) (a[la _dii;iocxl z'.x�.t:f ncc._.ir:to Incttu�-�nfocnua oo pczcz' w cIJ ooc7cr��) I am a sole propnetor and have no one work-mg for me. ( ) I am a home owner performing all the work myself. NOTE:plcsc be cwar clot wlu]c bomcownai who employ pci m w do ms;,-za C'X r a oa cr rcpar:wcrx on i d.clli�g of not mock dr_n thrno unibu in which the bomo�mid_ oc oc the V-0u as appurlcauri tbcc arc oot gcna-.fly cc s:dacd w be employes under the wlx rl cca;>e -atim Act(GL152,s 1(5)),applim-noo by a bomeow=fcr t l aasc a permit may a c lhc Icgal etpl, of an aaployar under dw Wockc et eompom ti Amt I undasr-and dmi x copy of tbi.ml.cwtsi may bo forw—d.ed tv tbo Dcpartmcod of lnduxri al Ana6—&Offi—of Gsnuiocc for the oova-xLS vcrificxuoc and that L-Ou c to smut oovcm&c under soction 25A of MGL 152 can Icad to tbo=PmdiO-of----1 penalties comisd g of a fine of up to S I X00.00 and/or bmpriioamcst of up to one y�and civil pcaLtia in dx form of a Stop Work Order and a fim of S 100.00 a day.grime me For dgxru*r�"• U_only Pcrmll Number — SignatlIrc of _t crmlticL �- ,# ". f- I.SECTION 8-CONSTRUCTION SERVICES i Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder 02-,P-V License Number Address Expiration Date Signature Telephone ', W, 4ft, im am Mak &I 04 ffi 3 wu A( Not Applicable 0 Company Name Registration Number ,P-e "3 DX /9-0 -711,L Y/a Address Expiration Dab 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. JdQgned Affidavit Attached Yes....... .0 No...... ❑ 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 buildint!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 IMSECTION 5SC ION PROPQSED WORK heck 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: <�< L �'/ ,�L�Y� �2.i//✓ Gs�/� ) 5?Jvi✓'� irir !'�/�''S s �y4« Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ SL' 44 r 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 I. A 41(f't 6.06:ioto &/SKw as Owner of the subject property hereby authorize /-A any _./ to act on my beh , i all matters relative to work authorized by this building permit application. Signature of Owner D e I, LA OLaLy -7 Y, 611 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. ned under the pains and penalties of perjury. s Print Name tiro /&� Signature of Owner ge Date 6 *� 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 f 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'tlhampton 2 6Buildin opartment .2 Street pEpT 100 NOR OF 81J7 pto MA 01060 phon �� r ,24b Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I-,SITE INFORMATION 1.1 Property Address: This sett Map lot ilnit � Zane Ose`hl*0i striljclt. Elm St.District GB©strict... SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: d/O6 L)L Im l-0 A&'o — 9 c e,,g/-3/zooe ,U/2'e"lf., Name(Pri Current Mailing Address: y/3 - 5�y- 5�0 72-- Telephone z5igna re 2.2 Authorized Agent: 114- a/0S-5 Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be official Use Only completed by ermit applicant 1. Building y Aga J (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 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 *►4000# 14 ACREBROOK DR BP-2000-0941 GIS#: COMMONWEALTH OF MASSACHUSETTS ap:Block:29-070 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2000-0941 Project# JS-2000-1729 Est. Cost: $4900.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Larry Yentsch 048666 Lot Size(sq. ft.): 12763.08 Owner: SADLOWSKI ALICE Zoning: URA Applicant: Larry Yentsch AT. 14 ACREBROOK DR Applicant Address: Phone: Insurance: P O BOX 120 (413) 584-4750 LE E D S M A01053 ISSUED ON.4/27/00 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE HOUSE ROOF & SHINGLE GARAGE ROOF OVER 1 LAYER 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: 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Aow Building 4/27/00 0:00:00 982 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo