16D-017 BP- 2011 -0503
GIs #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0503
Project # JS- 2011- 000825
Est. Cost: $1850.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARTIN CUSTOM MASONRY 77732
Lot Size(sq. ft.): 18295.20 Owner: KOESTER JAMES F & JEAN M
Zoning: URB(100)/ Applicant: MARTIN CUSTOM MASONRY
AT. 177 NORTH MAIN ST
Applicant Address: Phone: Insurance:
103 SHERIDAN ST (413) 592 -3595
CHICOPEEMA01020 ISSUED ON :121112010 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY
POST THIS CARD SO IT 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:
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:
FeeType: Date Paid: Amount:
Building 12/1/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
City of Northampton
��
Building Department,
NOV 3 0 2010 212 Main street
f ;
Room 100
Northampton, MA 01060
php�e 4131-587 -1240 Fax 413 - 587 -1272
F�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address � / /�� 4e- This section to be completed by office
N r �� Map Lbt Unit
Overlay, District
i
EfrnSt° °District CB.District
SECTION -2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Qwner of Record: A �/
J0 ZZZ
Na We (Print) ` Current Maili r��/ l � /ICL Ir
Telephone
ig ture
2.2 Authorize Anent: S 0 1"X 4
e (Pri Current Mailing Address: ol 2 o
(� /? ) 2, -�62�
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
J v
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 Onl
Building; Permit Number:
Date
Signature:
Building Commissioner /Inspector of Buildings Date'
Ak
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[:l Siding [[Zl] Other [
Brief Descri tion of P o 6
Work: V le /Ll L f�T��
Alteration of existing bedroom Yes Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
sa if l Wiit di e a c r a�'( d tiCa 1 "tmg r t ii m tee l � tl16w, a:
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. Masscheck 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, J Z _ �L as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative t wo d this building permit applicatio
t! 3d X f e
Sigfi Date
nJ �q C/v' as C ►r /Authorized
Agent hereby declare that the statements and information on the foregoing application are He and accurate, to the best of my knowledge
and belief.
Signed under pains and penalties of perjury.
P' ame
//16 ry
t o r /Agent Date
y r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
' 600 Washington Street
Boston, MA 02111
www mass gov /dia
- Workers' Compensation Insurance Affidavit: Builders/ Contractors /FIectricians/PIumb.ers
Applicant Information Pleas Print L iblv
Name ( Business /Orgmization/Individuat):. /�' f(/U> !� `�'N /// � (10
Address:
_ L 0 1 7194 S'T nc_c " CAI/ UU 16
City /Sta&Zip: L4i -b IW A - 61 Phone. #:
Are you an employer? Check the appropriate -box: Type of project (required):.
1. ❑ Zam Ioyer wi th 4.. E] I am a general contactor and I 6. ❑New construction
ees (full and/or part time).* have lured the soli- contractors
2.. sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and Have no e,n-451oyees These sub -contractors have .8. 0 Demolition
working forme in any capacity. cloyees and have workers' 9 ' B uilding addition
[No workers' comp: insuranc - comp. , -nor #
required] 5. We are a corporation and its 10. Electrical repairs or additions
3.0 I am a homeowner doing all work officers havexercised their 11 Q Plumbing repairs or additions
myself [No workers' comp. right 6f exemption per MGL 12. f airs
insurance required.] t c: 152, § 1(4), and we have no .
employees: [No workers' 13. Other /?S / . l�W * /
comp, insuranc rog6ired.J.
'Any applicant•that checks box #1-rnu also fiII out the section below. showing theirwotkets' compensation policy information:
t Homeowners who submit this aflidavit.indicating they are doing all work and thew hire outside contactors trust submit a new affidavit indicating such:
iContracton that check this box must.amiched an additional sheet showing the name of the sub - contractors and state whedXr or not those entties have
employees. If die sub - contractors bave employees, they trust provide their warl=s' comp. policy umber-
I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information
Insurance Company Name: .
Policy # or Self -ins. Lic. #: F- cpiration Date: -
Job S ite Addres _. City /Stawzip:
Attach a copy of the workers'; compensation policy declaration page the p9licy number and expiration date].
Failure. to' secure coverage:as required uueter.Section 25A ofMGI, c: I52 oa i lead to the imposition of cnminil penalties of a
fine up to $1,500.00 and/or one- year as well as civil penalties in the form of a STOP WORK -ORDER and a fine
of up to $250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Office of
I estrsaitions of the bIA for fn§urance coveraze vc ` canon a
I hereb
P P fPe the information provoked abQVe_islrue_asdrorrect__---
-- - -- - -- -l' - fy un_ a aurs•an
Si tore:
D a 0
Phone #:
Official use only. Do not write in this area, to be completed by city or town
City or Town. Nrmlt/Llcense #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical Inspector 5. Plumbing Inspector
6. Other "
Contact Person: Phone #:
• r
Massachusetts - Department of Public SafetN
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 77732
PATRICK J MARTIN
103 SHERIDAN ST
CHICOPEE, MA 01020
Expiration: 3/30/2012
Commissioner Tr#: 31089
,.- -" _ ✓1e - t�aninza�uuea�c o��/�.cra4ac/uia l
Board of Burmag Regutatiofis and Standards
HOME IMPROVEMENT CONTRACTOR
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MARTIN 0*0
PATRICK MA
103 SHEAlE AN S
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CHICOPEE, k164b1 Administrator
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License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Am 1301
Boston,
i
Not valid wi out signet re
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to:
rW.Mass.Gov/D
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