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24C-178 (3) Department use only `lt►:r.,_ City Of Northampton Status of Permit: Building DopBltmDftt Curb Cut/Driveway Permit Fa t ! ( 212 Main Str@@t Sewer/Septic Availability_________ Room 100 Water/Well Availability =` Northampton, MA_QIOQO Two Sets of Structural Plans phon@ 41 3=087=1240 RRx 4RI! � 1 Plot/Site Plans__ r--` V tirer Specify_ APPLICATION TO CONITRUCT,ALTS , RE AI NOVATE OR DE OLISH A ONE OR TWO FAMILY DWELLING I nil 2020 IRCTION 1 =BITE INFORMATION Nor�T lLDING INsa This section to be completed by office 1,1 Propeft Addml �— 4AAA! ON ' 01C ONS -- .�YC Lot � S+. �P_ 7 Unit 0 Zone_ Overlay District_ _ Elm St.District CB District INCTION I=PROPERTY OWNERINIP/AUTHORIZED ACENT titOwn, i Name(Print)4 Guff@nt Mailing Address: ig E;&'As�A Q�� T@lephen@ di n@taaF@ , Name(POn Cu f@nt Mailing Addr@l§*f S:L4A Y 13-j; q-q' - �ign Telephone 2jrd3 K!_ TIMATKD CONATRUCTION COlifii Item Estimated Colt(Doillaana)to be Official U@@ Only m Ieted by p@rmft as liq� _ 1, Building r— (a)Building P@rmit Fee 27 Efttriaol - - (b)Estimated Total Cost of Construction from 6 _ 3, Plumbing Building Permit F@@ b, Mechanical(HVAC) h, Fir@ Pmt@anti®n s. Total=(1 +2# +4 + 5) - Chock Number .Z - This n For Official Use Only Building P@rmit Numb@r: __-- Date Issued: Bign@tur@ building Commissioner/Inspector of batildinp Daat/e. P Ott, aS� EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) s Seastion d, ZONING All Information Must h Compl@taod, Farmit Can bas ftniod Du@ To lm@ompl@t@ Information Existing Propola@d R@qnir@d by Zoning 'Itis w1umn to hs ftll@d in by Building Mpommt Lot Sy Frontom E@tba@ks L: R: L: R: Hiiiding@i�Itt )Bldg,Squm Footage % Ap@n SPR@@ Foolag@ (W Am ming bldg&p 4vpta #of PRTWg 6R§@@§ volume&Location) X bays a Spacial R@rrnit/Variano@/Finding ever been issued for/on the site? NO ® DON'T KNOW YES Q IF YES, dart@ issued; If YES; Was the permit record@d at th@ Registry of Deeds? NO ® DON'T KNOW YES IF YES; enter Book Rasgo and/or Dootlrrimt# E. Does the site wntasin a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES IF YES, has a p@rmit b@@n or need to be obtained from the Consasrvation Commission? Needs to be obtained Obtained 0 , past@ Issued: C. Do any signs @dist on th@ property? YES O NO O IF YES, describe sizm type and location: D, qtr@ th@r@ any proposed changes to or additions of signs int@nded for the prop@rty ? YES ® NO IF YES, d@%crib@ sim, type and loation E, Will th@ construction activity disturb(@ aring,gradin®,00vation,or filling)ov@r 9 @or@ or is It part of @ common pion that Will disturb ev@r 9 B@r@? YES 0 N® IF YES,th@n a North@mptacn Storm W@t@r Management P@rmit from the DPW is requir@d. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) Now House 0 Addition Lj Roplsoomonl`Windows Alteration(s) ® Roofing Or Doors Accessory Bldg, ® Demolition E] Now signs 101 Decks IM Siding io] Other[IBJ BFl@#D@l�gFlptl®n of Proposed 13* 1\ ?-e IV'C�1 k+q IJ �{ � M'��/ TCS 1�IC 42zv��l IiUCAt u Work: Alteration of existing bedroom_-K-Y@§ No Adding new bedroom-_-- Yes '� No Attach@d N@rrat v@ Renovating unfinished basement Plans Att@ghed Holl - Sheet $a. If New house and or addition to existing housing, complete the folloyyln n a. Us@ of building°On@ Family_ Two Family Other____ b. Number of rooms in @anh family unit: Number of Bathrooms___ c, Is there a gorsg@ attaohody d, Proposed Squar@ foot@g@ of new oon0rudon, Dimensions @. Number of stories? #, Method of heating? _ __ Fir@placos or Woodstov@s Number of each g, En@rgy Dons@rvation Compliance, — Masoftak Energy Compliant@ form ottoch@dy h, Type of @onstmuU@n i, Is t@nstruttion within 100 R,of w@tlandsy Yes No, Is construction within 100 yr, floodplain Yes No J, Depth of basement or t@Il@r floor below flnishod grad@ k- Will building conform to the Building and Zoning regulationsy Yoe No 1, Septic Tank City S@w@r Private well City water Supply RECTION 1s•OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERi AGENT OR CONTRACTOR APPLIEi FOR BUILDING PERMIT 1, lL ,as Owner of the sub)@Gt property to att on my behalf In 911 matt r@ Fk thorixod by this building permit a plicotion. oz- �i2 Iti nags @wncr Dai 11 I � LS ,as Owner/Authorized Ag@nt @r@ @ aF@ atthe statements an In tion on the foregoing application or@ true and 000urat@,to the best of my knowledge and belief. Signed and @ pains and p@nalti@ p@Bury, Pant N i Iii nature of ow wl Dat UNCTION I-CONiTRUCTI©N SERVICES 8.1 Licensed n Supervisor: Not Applicaft 0 Name of License Holder � L ( - ��� C—S-- Q r7 1nO(�k%j _ Lfw@nti@ Numb@r MAC, 4 Oz1 ��g3 l Ex0folion Date "ognature XT@l@ph@n@ _. Rei Not Appli@@hl@ P-i j (e k R@gi6tra on Numb@r 3 Ns#- , 1 - 0(30 / 46 0g ot0�� Addr@§§ - - Splr@tt@n Om T@I@ph@n@ x(13-3?2-4105- SECTION 10-WORKERS'DQMFIQNSATIAN INSURANCE AFFIDAVIT(MAL.0. 1i 2,ij 2IICM) W®rlIm C@mp@n§atiAn InsNFanc;@ affidavit must he completed and submitted with this application. F@ilur@ to pr@vid@ this @fIdsvit will r@@ult In th@ d@vial @f th@ i@§u@n@@ of th@ huildin @rmit: Ili n@d Affidavit Att@@h@d Y@&,- N@:.:::: The Commonwealth of Massachusetts Department of IndustrialAccidents 1 Congress street,Suite 100 Basten, MA 02H4-2017 wwo%mass jav/dla «ovke"O Compensation insuranc@ AMdavitt wild@r@/Contractoro/El@etriciano/Plumb@m. TO RR FILED WITH THE PERMITTING AUTHORITY. Applicant Info NAMAli>min@� (��rpit}tit�n/indiv#41)� - Addross. f7 w&Lsk S : C(ty/stwo/Z(p; M . 0(3w Phone #: Art you as ompl yer?Chwik the npproprint@ hose - `IPyp@ of proj@ct(requir@d): 1,®1 am n @mphfx@f with @mplor@@s(full arwor p4ortin** 7. ®N@w construction z:ai nm n.ol@ propri@tor or pmfn@mhip and hav@ no @mploy@@s working for m@ in a, rMRomod@ling my @npwity-[No workers'comp,insumoc-@ r@Quir@d,l15 4,®1 am n hom@trwn@r doing ail work mywif[No workers'comp.insumopp r@quired-1 t 1 Building 4,®1 nm n hom@owo@r gad will W hiring wotr wMm to wodu@t fill wont on"w ro rty_, I will I®®�ifiid n�Addition @n.uf@ that fill @oatfn@tof.@iM@f hav@ work@"'@omp@rtnntion*vfiln@@ or n�40 9 i LEI l i@WO#i mpg[rs or additions proprimn with no @mploy@@s. 12,[3 Plumbing mpitirs or odditionfi 3-C]14m o p@n@rnl @oommor and I hnv@ hir@d th@ soh @ontm@tors IWO on th@ @Mwh@d Am. Th@s@ sub @oottors hav@ @mploypps and hnv@ work@rs'@omp.insuran@o b,®W@ arc it @orporntion find its officers hav@ @rt@r@is@d Owir right of @a@mption p@r MOV P. :® ►@r 111,110),nod w@ hnv@ no employ@@.,[No work@r.'@onw.insufan@@ rquirnfl *.Any applicant that chegkq h@tF N1 must also fill uutth@.@f a h@i®w.howing th@if Work@rs'@Lifllp@n.ation po11@y Informatloa- t tium@owners who submit this affidavit indipating th@y fir@ doing all work and then hir@ outside contractors must submit a n@w afldnvit iadi@nting swh. fC—ontfn@tors tont @h@@k this hut€must attaFh@d an addiflooal sheet showing the name of the sub-contractors and state whether of not thA.@ @ntiti@.hnv@ @mploww Ifth@.N @untfa@fAr6 hnv@ @mploy@@s,th@y must provide their workers'comp.polic) number. I am an @r►tplay@r that A providing worll@rs'co,rrpens(olan 1nvmranive jor mV employees, Below is file palm and jah iilt@ h1f0Fin9t10n, Insltrgn@@ Company — Policy#or SONns,bi@.#:_ ___ Expiration pat@; Job Sit@ Address- _ _city/stat@/Zip: Attach a copy of th@ work@",compensation policy d@c[arntion peg@(showing tb@ policy numb@r and @apiration dot@). Fail=to s@cur@ @ov@rggo as r@quir@d under MOI,@, 152, §25A is g criminal violation punlshgbl@ by it fin@ ftp to$1,500,00 and/or on@=y@gr imprisonm@fit,g4 w@11 a civil p@na1t1@s in tb@ form of it STOP WORK ORDER and it fin@ of up to 5250:00 g day against th@ violator:A copy of this stet@mont may be forwgrdod to th@ afilo@ of Inv@stigotions of th@ IIIA for Insurgno@ @ov@rag@ v@riflogtion. Ida h@r@by Im r til@ pa ar peaairies a/p@rjnry that the Wormatlan provld@d abav@ is true and carr@@A Phone#= Ll 13-3 6 1)— q ICK - — o iclal n90 only, 00 net writ@ In thk arca,to he completed by @I(v or town official _- -- city or Town; P@rmltfLle@ns@# Issuing Authority(cirri@ on@)i 1,Board of iii@olth 2,Building Npartm@nt 3,City/Town Cl@rk 4.Pi@etricol insp@etor b,Plumbing Inspector 6,®th@r Contort Persons Phonc#: - — City of Northampton Massachusetts j -A± . 1 11 . rl•- WFAMMM OF MUDIN9 XWBPECTIONS ti@€ a-Pt®@, M 01060 iggC' Debris Disposal Affidavit In accordance of the provisions of MOL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Pormit shall be disposed of In as pFop@rly licensed solid wrist@ disposal facility, as defined by MQL 6 111, 6150A, The debris from construction work being performed at: I `�S Cae__Scw-t-� (Pleas,@ print house number and street name) Is to be disposed of at: (Pl@@§@ Print na m@ and ons ion of facility) OF will be disposed of in as dumpstor onsite rented or leased from., I,lpati s 20 O 0 4-eL �R7-sit ompany Name vi Address) ignotur@ of P P6 F to of Owner Daae If, for any reason, the debris will not be disposed of as indicated, the Applicant or Own@r shrill notify the Building Department as to the location wh@r@ the d@bris will be disposed. _ City of Northampton Massachusetts _ '{ AE-PAROF MUILMNO xNsPEcryowd 212 main ®t-€@@t • 1a1p41 I" a 01060 AFFIDAM Hom@ improvement Contractor Law Ouppl@m@nt to Permit Application The Office of Consum@r Afbirs and Business Rqulation("OCABRI')roplat@s the registration of @ontra@tors and sub@ontra@tors performing improv@menu or renovations on d@ta@hed one to four family homes. Prior to performing work on such homes,a @onus@tor must be rglst@r@d as a home Improv@m@nt Contractor("MCI'), M,G,L, Chapter 142A requires that the I'moon@Iru®tion, @It@mtion, renovation, mp@if mod@mimti®n, ®®nv@mi®n, improv@m@nt, removal, Wm®liti®n, OF GOnstnt@tlon of an addition to any pre-existing owner=occup4d building containing at Imot on@ but not mom than fouF ft0ing units.:::of to stotctums which are adJacont to such m0donao of buildings"W done by contra@tors. Note.If the homeowner has contracted with a corporation or IM that onto must he rsgktsrsd Type of Work! - Fit,Cost; .Address of Work; Date of permit Application,, I hereby c@rto that: Rgfstratlon is not rewired for the following reason(s): Work @xolud@d by law(@aplain),. —Job under$1,p00.00 _Owner obtaining own permit(mplain), building not own@r=o@@upl@d Other(spe@W), OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORD ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M,O,L,Chapter 143A,SUCH OWNERS ALSO ASSUME THE RESPONSIBILITEN FOR ALL WORD PERFORMED UNDER THE BUILDING PERMIT,SEE NEXT PAGE FOR MORE INFORMATION, Signed under the p@naltl@s of p@dury I hereby apply for a building permit as the went of the owner; Date Contractor dame IIIC Rglstratlon No, ®Rt Notwithstanding the above notl@@,I hereby apply for it building permit as the owner of the above property: Date Owner Name and Signature ,rs dan`rbvq+ `�'•�^eoaaercr.e�gHmr�wmwt.N�r�kab..� rtia:sBar�1.,ai......a+�vfie�;6B:tilra.,em"So apmls+tlTeebiii'rd.•3b.+eotss;�ied..p�eiv�a."ate M p2-� ocoovm oZQm <�iMy o�ry u C AUT. 2 6012 iju a>>-1 2T 'Tqy .O-H�y , £j[E� f1�, �Q G•=-� � y�� �C S 2100 tj � o2 a a�> Oq x2mo(�; ; �yj irn c a R o n A N TYA � 2z . i9 ta- FaR gc �Mg �` wm z� xo afz z Fo Oax 27 I�d � 2U � � z r; o g � c � Fao c � o � PH my i3 >� >� �� �zy aK mC ' a S= �'� z ��o a$ �mz o > �Q� eomz "3 m ® C,°z> f vqz imzA& as <d as c m ex $ z F S n m m o 0 L i ii AM! e�i� IIAMN FLOOR Phi oince 4H§3 M,84;1s3 iis-kfla-ws:oain _---