37-078 (7) 49 PLATINUM CIR BP-2001-01 97
GIS#: COMMONWEALTH OF MASSACHUSETTS
lap:Block: 37-078 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0197
Project# JS-2001-0318
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 36241 .92 Owner: GLEASON DANIEL&ALLISON
Zoning: SR Applicant: GLEASON DANIEL & ALLISON
AT: 49 PLATINUM CIR
Applicant Address: Phone: Insurance:
49 PLATINUM CIR
FLORENCEMA01 062 ISSUED ON:8/22/00 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR SHINGLED ROOF
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:
Building 8/22/00 0:00:00 5843 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit _
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability_
Northampton, MA 01060 Two Sets of Structural Plans______
phone 413-587.1240 Fax 413-587-1272 Plot/Site Plans__..,1:
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
p/-/ PLArinJvrt G',)t Map Lot Unit
j,,�/� `& r t14 o!v/'- Zone Overlay District
r '�'� �l Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /J
i v * �l 64 /�!-14rl ,, r//1.Gt-�
name • t) . " '✓ C ikM t
A d�/>5
/1 µk 0 062_
Signature 9
rr) Telephope
iT(3 5&q'
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building tfizw (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) "'2 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIE : DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ' 1 ka
UKs
Frontage / 70
Setbacks Front
Side L: R: L; R:
Rear
Building Height
\ I
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 X 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:
CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
I New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing yxt
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ,] Decks [ ] Siding[ ] Other [ ]
/Brief Description of Proposed Work: A'( iZao Ie Lr 5+4 0 4 61E5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ . Sheet❑
afiltNtik,hoes+ 'tC1". tQKelifN !`t' t . i g; Q11'1p] 'te':. '1 'af„+f ld
a. Use of building : One Fami Two Family Other
b. Number of rooms in each famil nit: Number of Bathrooms
c. Is there a garage attached? /'e
d. Proposed Square footage of new construc ' n. Dimensions
e. Number of stories? 01
'
f. Method of heating? Fir p sr •odstove Number of each
g. Energy Conservation Compliance. Masc nergy 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, /6( J &L 5OY1/4 , as Owner of the subject property
hereby authorize to act on
my be : in all matter Jrrelative to work authorized by this building permit application.
-"a-9Signature of Ow Date k / d400
eitx; , as Owner/Authorized Agent
hereby declare t t the statement 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.
D,gi✓it, 5 G 1-0+5o 1
Print 466011
Signature of Owner gent Date , /?//.1CIre)
I
SECTION 8-CONSTRUCTION SERVICES
I Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
€
,:ifige4 Not Applicable 0
Company Name V
P Y Registration Number
Address Expiration Date
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.
ci7ned Affidavit Attached Yes 0 No 0
►�exerterneEP nip ion
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, d Local Zoning Laws and State of Massachusetts General Laws Annotated..
Homeowner Signat
• - .
9��4.411 ,4 �fl QIYZ ��lIC�JIIIt i -'♦ r
$�t�i�`� 6 Zsancllasetla 1%.
I �� �ii
�'� DEPARTMENT OF BUILDING INSPECTIONS == -__
212 Main Street ' Municipal Building
Northampton, Mass. 01060 see'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
(ii censec/permi ttee)
with a principal place of business/residence at:
(phone#)
(stl tzt/city/staff/ap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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) (Insurance Company/Policy Number) (Expiration Date)
1F
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
1
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional slant ifno,-tor ry to include information pertaining to all ooatractora)
( ) I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
•
•
NOTE:please be aware that while homeowners who employ persons to do ma inrr„aisre,construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto arc not gwerally considered to be
employess under the worker's rnmt{rnstion Ad(GL152,ss 1(5)),application by a homeowner for a license oc permit may evidence the
legal status of an employer under the Wocka'a Compensation Act_
I understand that a copy of this ctatemeat may be forwarded to the Departascnt of Industrial Accidents'Offroe of Insurance for the
coverage verification and that failure to secure coverage under soctioa 25A of MCOL 152 can iced to the imposition of criminal,penalties
consisting of a fine of up to S 1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.00 a day against me.
I
Foe departmental use only
LL Permit Number
-(� , L� Map# Lot ti .
� Signature of L. •ermittee Date