10B-030 M- 11 1 BP -2010 -0228
GIS # COMMONWEALTH OF MASSACHUSETTS
" A CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0228
Project # JS- 2010 - 000286
Est. Cost: $15143.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO 066189
Lot Size(sq. ft.): 12458.16 Owner: GOLDSMITH JONAH S & LISA S
Zoning. URA(100) Applicant: RICHARD DENNO
AT. 63 GROVE AVE
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584 -0852
FLORENCEMA01062 ISSUED ON :812812009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 8/28/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northamptonr�
Building Department
a= mei. 6 Z M s 7 7 .
21.2 Main Street rlg
Room 100 71+yaiii � �
r � �" Northampton, MA 01062 '
phone 413- 5$7.- -1-2 Fax 413 - 587- 1272���
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
Map Lot..: Unit
cu e2l d I , Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Ow er of Record A �a
rA Name (Print) Current Mailing Address:
Telephone
Signature a�S6
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
std " C5 7
Signa ure Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building Ov (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) /.� �.s Check Number
This Section For Official Use Onl
Building Permit Number: 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
p arkin g)
It 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 l 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes z < No Adding new bedroom Yes �!r No
Attached Narrative ❑ Renovating unfinished basement Yes --pr No
Plans Attached Roll o - Sheet ❑
6a. If New, hetlse and or add Rim ttn existrgti carpfete the fcltarri
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
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? -Yes
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
1, /sue , �� s�4 , as Owner of the subject property
hereby authorize Gee, V & ,a ,b to act on
my behalf, in I matters relative to work authorized by this building permit ap lication.
Signature of Owner Date
j7�� as @M%r /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
Signature of Owner/Agent `� ate
O�Z 1tAN P j ,
`�"�' yti (rx of �IIl" #t�g111�IfII11 - —
�asaxrhnsrtla =
d DEPARTMENT OF BUILDD\ INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVTT
with a principal place of business residence at:
Ss'l ��•�Y, !U �..� /ZZ6 ,! , ,, 1% r ®sad P honei') S�
(srr�t/ci ty /slal tr�n p )
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:
(Insi=cc Compaml) (Policy NtL -bcr) ( Expimtion Date)
() I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the followu3g worker's compensation policies:
(Name of Con�Tactor) (1 ran t" Company/Policy Number) (Expiration Datc)
(Name of Contractor) (Insurance Companyi?ohcy Number) (Expinllion Date)
(Name of Contractor) (Insurance Company/Poticy Nusbes) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiomi thee ifnocrasary to inchidc inforuiuioa percnining to all ooarnctzn)
I am a sole proprietor and have no one working for me.
() I am a home owner performing all the work myself.
NOTE: p(csc be aware that whilo bomeowners who employ pawns to do —rm3 ncc construction or repair work on a dwelling of
not morn than thmo uniu in which the homoowncr rc=dc3 oc on the grounds appurtcn tbceto are not gaocr,4 coatidcred to be
employen under the - vckrr`s oemQassaiioa Act (GL152, 1(5)), applintion by a bomeowncr far a lieeax or permit may cvidcax the
IeV1 atanu of an employer under dw Woricoh Compomaiion Act
�v.. I understand that a copy of this ctatemcat may bo forwarded to tho Dopartmcoa of tndzis d Aoadm& Offioo of Iaarrwoo for the
covaage verification and that Ld r+c to aoanc coverage antler socdon 25A of MOL 152 can lord to tbo imposition of aimiwl pcaahi-
eoa-* of a fine of trp to S1,500.00 anNor imprisonmcai of up to one year and civil pcaahies in the fora of a Stop Work Older and a
fins of S 100.00 a day against m
For dcQat =n3W use only
i PeTmit Numbcx _
✓ °, / di Map- Lot R
uat
e
c
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder ,fir -„���✓ �� �j ��
License Number
JltY �Q ��A co 1 -- o Z :2 4 , A, 4
Address Expiration Datelf
Signature Telephone
Qr
i prtreebi�Cgn#t' Not Applicable ❑
4 - %4. , / 2,O 46 6
Company Name Registration Number
Address Expiration f5ate
a, 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...... ❑
it
ow
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 buildins 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
63 GROVE AVE BP- 2010 -0228
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map-.Bloc IOB - 030 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: BUILDING PERMIT
Permit # BP -2010 -0228
Proiect # JS- 2010 - 000286
Est. Cost: $15143.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO 066189
Lot Size (s g. ft.): 12458.16 Owner: GOLDSMITH JONAH S & LISA S
zonina: loo)/ Applicant: RICH DENNO
Applicant Address: y Phone: insurance:
551 FLORENCE RD (413) 584 -0852
FLORENCEMA01062 ISSUED ON :812812009 0 :00 :00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy sip-nature:-
FeeType: Date Paid: Amount:
Building 8/28/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo