23A-005 (2) BP-2002.1015
cJs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-101.5
Proiect# JS-2002.1652
Est.Cost:$25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const, Class: Contractor: License:
Use roue William Gnatek 017240
Lot Size(sa.ft.): 34020.36 /ween S5 VE S E i N JR&MAVI L
Zoning:LrRB Applicant: William Gnatek
ST: 36 MEADOW ST
Applicant Address: Phone: Insurance:
P 0 Box 204 (413) 584-5682
HADLEYMA01035 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:STRIPPING AND RE-ROOFING HOUSE AND
PORCH ROOFS
POST THIS CARD SO FT 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:
FinalFinal:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMFT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: ------ -211r#
gel
Fee Type: Receipt No: Date Paid: Check No: / Amount:
Building 0826 $25.00
212 Main Street,Phone(413)587-1240,Far (413)587-1272
Budding Commissioner-Anthony Panino
nV l y of Northampton
L c E ° t' llding Department '�-
•1 12 Main Street r r, ax vir t
MAY 2 0 2002 ll) Room 100 I t n
` sal (Hort ampton, MA 01060
�..------- fttkyau 40.1.3.5 71240 Fax 4135871272
ry L!
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This recti o b,p,o,mp
1.1 Property,.Address: ({�[ Nh d#` r
oiL p
3(a /nPfcdee reed Mai tot
Zone . Overlay`D-rstrict vrr w
! Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tanis Stevens 36 Meddc,u St 2.49„-a-t1c e y Ma- etta
Name(Print) Current Mailing Address:
It re til 2LdV/ 2 ,-s-WY- -2SY
Telephone
Signal e
2 2 Authorized Agent:
Name(Print) Current Mailing Address
Signature Telephone
SECT!,N3- _STI ,•TED ON TRUCTION *STS
Rem I Estimated Cost(Dollars) to be Official Use Only
completed by permit a'•licant
I. Building (a) Building Permit Fee
4•#1. 00
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) DOD- de) Check Number
This Section For Official Use Oni8
Building Permit Number: P— Let9L—!C7C , Date Issued: J
®20°Z.-_
Signature:
Building Commissioner/Inspector of Buildings 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
'hy Lot Size
Frontage
Setbacks Front
Side L: R: L: It:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
ii 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. Are there any proposed changes to or additions of signs intended for the property ?YES_
No
IF YES, describe size, type and location:
•
SECTIONS-DESCRIPTON<OF:PROPOSED:WORK:(thrck.All applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)0 Rooting
Or Doors 0
Accessory Bldg. ❑ i Demolition❑ New Signs (, ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: `.*r . ,' rereten9 Acute And parch jPirn $
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative U Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet❑
sa.Iff kVA imx i;,,td , iti T to'e_igt flbal0 in! eco ",..C- liar"&s.' .rot&:
a. Use of building • One Family Iwo Family__ Other
h. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? ,_
d. Proposed Square footage of new construction. Dimensions.
a. 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 ftof 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 .
F. Septic Tank City Sewer Private wen City water Supply
SECTION 7a-OWNERAUTHORI,ZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR'CONTRACTOR APPLIES FOR BUILDING PERMIT S
�71 CCZi s te re yt$ /'} , as Owner of the subject property
hereby authorize 6t�r`AAiy et vu. 4? YI Qt' to act on
my t , all matt
to work authorized by this building permit application.
Signat re `Owner Date
1, ULU(grvt l2/'a Y10.Dek„ 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.
W 1 C( ! A th GAMTn�C
Print Name
artCc.,Lc�4 s '/J"&
Signature of Owner/Agent Date
SECTIONS•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /�• t, 0�• /Not Applicable�/ 0
Name of license Holder: 1,01rL.L✓1_ On/-N na-/ e-^ -_ 4/e
License Number
C .U. R0* <Joy Raynay .P10.2 O/v
Address Expiration Date
e9/3i d71i-517A
'-5 Signature 7elephonec1
Ai
L-t-Y3 mt— 8;pj jIIuY - u u , M`ntra nt " x:i"""> •,ys. Not Applicable I7
Company Name Registration Number
W;/.Jiarn ..Oate.k ($n frnd tr DG ,914,/
Address Expiration Date
• l.Q. 0 • 1 ate //4. '0,flelephon,�1 dill' Sr 912
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 bulldog permit.
Signed Affidavit Attached Yes ❑ No t '
IFoka 1
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 helshe 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
.b¢ t (fzfR x>f Nnrfliampfnn i "
2 1r�;,
Bbfi 16 Jilxssxtpna<ita' at1
•$ ; =_ DEPARTMENT ON BUDDING INSPECTIONS ,t•'=I=
212 Main Street Municipal Building
Northampton, Mass. 01060
WORKERS COMPENSATION INSUTRANCF. AF`FIDAViT
l(�1 �i4wi Cnrt2et
(dcenstcJpermitiec) _.. .
with a principal place of business/residence at:
aS &5 ell- ift Mir�iej, ma mins-(pbonet�i94A5741-S2:0/
(sutcttcitytsiatrtrip)
do hereby certify, under the pains and penalties of peljnry, that
(L-I-1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
Guam ins (xrrluN lulu) J.'4 74( o y- -ei
(Instream=Company) (Policy Number) (Expiration Dale)
) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurnnce Company/Policy Number) (Expiration Date)
(blame of Contractor) (Insuanx Compasy(Policv Number) (Expiration Date)
(Name of Contractor) Qnsrrance Company/Policy NumMr) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Ni )nnber (Expiration Date)
(aaa.L 4ticetilabaci if ouxsuy to bitlwk information pertaining to di macron)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE:Memo bc aware that.tile homeowner,wk bmokiy pc..,...to 4 tai ,,.,..— ccIllyuctio0er AnonAuk of a awsns of
not,ury thin three units to iattidt tie M,owormikes or no the vomit mom:tan th&do to twt gmc%@y mt:idut4 to he
employ=under the%cttkttn cr.rrFetim Act(GLr52p1(5)),14),U-calico by n kowtow=far a Gare cc petmit may ^4u.—the
legal status AFm eploya<"aaSxr Wn Wor4.o:a Con pa stion An.
uo-knuvd thata copy ofMIAnatancaa may be fmnntd>)to the Dernutenit of Fr=ill Anitstaa,Ohm of limumon for Ma
ookcetztattifiafioa and that r&MLse to aavre COVCn e unet axtim 25AcLMOL 152 on i=dle the imp mm ofaimmM pmateia
cemutfl,gofxf a of IDIS SI.5W.O0 mVrimµ:x..r,.atofup to ere xrz4dv7 p®nua in tbcf Of Shp Work Order ec4x
Eno of SIOO.00*clay against cut
Fofeepm,e,+at un mh'
Permit Number
. s=I!3—a MaP4 iota
.S4tac$+3.x.. . $l�:lb.RC bfr..ItFpS(yfpClIDr[(CC .IhtE _ F,