29-393 89 BROOKWOOD DR BP-2011-0869
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map.-Bloc 29 - 393 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2011 -0869
Project# JS- 2011 - 001427
Est. Cost: $1600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: OLD HADLEIGH HEARTH & HOME CENTER 98784
Lot Size(sg ft.): 10802.88 Owner. ZELAYA BLANCA M
Zoning URA(100 )//WSP Applicant: ZELAYA BLANCA M
AT. 89 BROOKWOOD DR
Applicant Address: Phone: Insurance:
89 BROOKWOOD DR (413) 387 -7529 () WC
FLORENCEMA01062 -0205 ISSUED ON:412912011 0.00.00
TO PERFORM THE FOLLOWING WORK.- REPLACE WOODSTOVE INSERT
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 4/29/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
rA a I 101 ys• C
D Department use only
ty of Northampton Status of Permit:
ARM B ilding Department Curb Cut/Driveway Permit
AR r � [Q) 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
DEPT Qr RL c ti:V " Noithampton, MA 01060 Two Sets of Structural Plans
NQ � =-15ho 87 -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
Q'� �✓l ,. p�i� �� � vim. Map Lot Unit
O G � M A� O' O / t7 2 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
p 2. V42-
Name (Print) Current Mailing Address: ' L' _ 3 9'7 2
Telephone "[
Signature
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 ermit applicant
1. Building (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 = 0 +2+3+4+5) ICJ oco sfDle f 6Oo • Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 )Vj
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved O D I
p arkin g ) G(
# of Parking Spaces
S+°��
r e� l
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [O] Other
Brief Description of Proposed �^e j �� W 0 s �y e
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 5'�/� �� " ` ��n , 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. �y
V1T N✓� ' / v t' � /'�
Print Name
Signature of O er /Agent Dat
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor // Not Applicable ❑
Name of License Holder : Cc ( S S(- 7 b ?
License Number
J(1 <<- a F ()
Address Expiration Date
Si ature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
v1c� /`l ra?-
Company Name Regis rt ation Number
Address7 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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) lamilies
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 buildine 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 responsibilit for compliance with the State Building Code, City of
Northampton Ordinances, St t d cal Zon' g L and Sta of Massachusetts General Laws Annotated.
Homeowner Signature