23A-186 (3) 8 PINE ST BP-2001-0256
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A- 186 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2001-0256
Project# JS-2001-0432
Est.Cost: $1800.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: David Johnson 055903
Lot Size(sq. ft.): 39291 .12 Owner: SYSKO HENRY L&MARGARETE
Zoning:URB Applicant: David Johnson
AT: 8 PINE ST
Applicant Address: Phone: Insurance:
P 0 Box 390 (413) 268-7389
WILLIAMSBURGMA01096 ISSUED ON:9/15/00 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT NEW 1ST FLR BATH WITHIN
EXISTING
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: 'rK1/(9/dd Rough: House# Foundation:
Final:Ki4/4190 Ao Final: ) d/p U v
ym I• Rough Frame: Ch ,),7106_1 ''
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: b 1, ( - / Tel -11"
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
j7°447 -42-44 -414
Certificate of Occupancy 165.
re:
Fee Type: Receipt No: l Date Paid: Check No: Amount:
Building 9/15/00 0:00:00 395 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0256
APPLICANT/CONTACT PERSON David Johnson
ADDRESS/PHONE P O Box 390 (413)268-7389
PROPERTY LOCATION 8 PINE ST
MAP 23A PARCEL 186 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid L39csVSO
Typeof Construction: CONSTRUCT NEW 1ST FLR BATH WITHIN EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055903
3 sets of Plans/Plot Plan
THE 1�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
-"k9--/3.00
Signature of Building 1init
al Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
Department use only
D C 0 M Northampton Status of Permit:
U i g Department Curb Cut/Driveway Permit
SEp ' y� Main Street Sewer/Septic Availability
2 / Room 100 Water/Well Availability
DEPTOFBUII �� Northampton, MA 01060 Two Sets of Structural Plans
NORTHtit�;Pl° ,V87-1240 Fax 413-587-1272 Plot/Site Plans
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
�,% Phi f Map �3 ft Lot j zS6 Unit
Zone Overlay District
FlOv-por.P M
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N �(punt) Current Mailing Address:
Telephone p —
Signature i S Q y of sl t_1
2.2 Authorized Agent:
Rt., •n.m,/� PC Aox 3 0 6 /( r«ur,rbf,A0
Name(Print) Current Mailing Address:
�4I0, F73F9
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building Gb (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 396-- _ 0 —
This Section For Official Use Only
Building Permit Number: pd I — 122514) Date Issued:
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
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 V 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:
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s)g Roofing D
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] ptber`[ ] (Qij
Brief Description of Proposed Work: .1-v'S* (1 M.R,&jrtro� it N.�J&#h
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Li Renovating unfinished basement Yes No
Plans Attached Roll i i • Sheet❑
68.'' it 1 ,-. I T _PJ ! .L+ Jt Li Lill: Val A-7 ..I It"i.1 t ' i tt ° ='.t 6 . :' i:
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
I, Ram e'k..i J LiS 'w _ , as Owner of the subject property
hereby authorize to act on
my b$+h If, in all matters relative to rk a 1hor. • by this building permit applicationtiio /
,�,(f� g . 4e& • ' �L 1 216�'
� �
►' Signature of Own r Date
I, ,404AvI6.4 Y1tn.s1),/‘ , 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
041 p-- /d --od
Signature of Owner/Agen Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:/ �.--P� Not Applicable 0
Name of License Holder: �^)f}v (77d 067.5-90 3
License Number
•
1'i $,eta✓ 4;0 6 - W file vvt oA Din 6
Address Expiration Date
- 5 Q-t - vaEor736.9
Signature Telephone
•9. Registered Home Improvement Contractor: Not Applicable ❑
1 T3 4�2
Company Name Registration Number
kb-6 £ CCIt Nce-0 -7— 7-0
Address l' r Expiration Date
"/YQrrav 1 ;1 1 act &. f wtl'txavDTelephone
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.
Signed Affidavit Attached Yes No 0
11. - Home Owner Exemption
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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r • .
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'W — DEPARTMENT OF BUILDING INSPECTIONS _:e�g _
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 um"'
WORKER'S COMPENSATION INSURANCE AleiaDA.VTT
I,
(liccnsee/permittee)
with a principal place of bltsiness/residence at:
• (phone#)
(strreet/city/start ip)
do hereby certify, under the pains and penalties of perjury, that:
t`
1;'1 ( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
t
:; , (Insurance Company) (Policy Number) (Expiration Date)
:ji'. ( ) 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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
• (attach additional sheet if necessary to include information pertaining to all contractors)
Q4 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 mairKe.,wn,construction or repair work on a dwelling of
not more than three units in which the homeowner rendes or on the grounds appurtenant thereto are not generally considered to be
employers under the worker's oempesssation Ad(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal statua of an employer under the Worker's Compensation Act.
I understand that a copy of this statement may be forwarded to the Depertmmt of Industrial Accidents'Office of Innuanoe for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
resitting of a fine of up to S1,500.00 indlor i prisoamart of up to one year and civil penalties in the form of a Stop Work Order and a
find of 3100.00 a day against tee.
For departmental use only
P
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Lot
Signature of Li 4. fPermittee to
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