42-063 City of Northampton
Building Department
212 Main Street
Room 100 1, 4 �
Northampton, MA 01060
C Lv phone 41'3- 587 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address
Map Lot Unit
�� V
Zone Overlay District
EIm St. CB District
SECTION' 2 - PROPERTY' OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of R co : Ave
Name (Print) + Current Mailing Address:
Telephone
Signature
2.2 Authorized A
Nam (Print Current Mailing Address:
10. 0 64, — I I ! 4
ig re Telephone
SECTION - ESTIMATED!CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com feted by ermit apalioaDt
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6,
3. Plumbing Building Permit Fcc
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 324 + 5) Check Number L l S r
This Section ForOffc al Use Oni
Data
Building Permit Number: Issued:
Signature
Buildirg Commissioner /Inspectorof Builiiings Date
y
i
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:
Rear
Building Height
Bldg. Square Footage
Open Space Footage --------- %
(Lot area minus bldg & paved_
p arking)
# of Parking S aces -- --
Fill: �
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #w..._
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained
0 , Date Issued: ;
C. Du aiiy signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
"` - zn -- r� °t�ierP �n — rn mad r an as to nr a = : ttinns n c ns intPn Pri fnr the P (i Y rn Prt 7 YFS 0 NO
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition 0 Replacement ows Alterations) � Roofing F7 moors
Accessory Bldg. ❑ Demolition ❑ New Signs (❑] Decks [C] Siding [❑] Other [❑]
Brief Description of Proposed
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 h�evu..F�ouse= aricor adittlfln�to:e ' �n cousin "= ..com` life th�f+�llauuin °
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 st ories?
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
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
IAJF� 1013 as Owner /Authorized
Agent hereby declare tNf t e sta emen s and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed and ' s and pgnalties of perjury.
.!�
Print m
Sign a of caner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: / Not Applicable 0
Name of License Holder: % 1 YN { 1��� Vx I•�cg
License Number
Address I Expiration Date
) ZA q ot
Sign a V I Telephone
9:;Re sfeibdhlntne:l rra� "'en# Go ;rtor " Not Applicable ❑ Q
Company Name Registration Nu
Ad ress Expiration Date
Telepho
SE CTION 10- WORKERS COMPENSATION INS NCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi permit.
Signed Affidavit Attached Yes....... No...... ❑
� NM "'P.
The_ current _exemption, for _`_`homeowners ". w 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 consid a h omeowner .
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 Supervisur yuur presence on the job site will be required from time to time, during and npnn
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
-- -- -- Massachusetts -General. Laws Annotated.
o ampton r manes, a
Homeowner Signature
j
{
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
~� whW mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A olicant Information Please Print Legibly
Name ( Business /Organintion/Individual):
Address: M"J
City /State/Zip: Phone. #:
Are yo
4.. employer? Check the appropriate box: Type of project (required) :.
I l contractor and I
1. I am a employer with [L ❑ am a g enera 6. Q New construction
employees (full and/or part- time) -* have hired the sub- contractors
2. Q I am a sole proprietor or partner- listed on the attached sheet. 7- Q Remodeling
These sub - contractors have. -
ship and have. no �.�loyees T 8. Q Demolition
wor king for me in an capacity employees and have workers'
Y � �'- . # - 9. Q Building addition
i
[No workers' comp. insuran comp:_ insurance.;
required-] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
offic ezzlia_v e ° 11 in
�. ❑ I am- aemeo-waer d a ail�vc�rk - -- - - -- ❑ g ;ePairs or additions
myself. [No workers' comp- right of exemption per MGL 12. Q R repairs
c. 152, ,
insuran required:] t § 1 4 and we have no (� 13 Other
employees. [No workers'
comp. insurance required}
*Any applicant that checks box #1 must also fin out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit:indicating they are doingalt work and then hire outside contractors must submit a new affidavit indicating such_
1 contractors that check this box must-attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
formation -- -
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date: -
Job Site Address: City /State /Zip:
Attach a copy of the workers'" compensation policy declara tion page - (showing the policy number and expiration date).
Failure to- secure coverage': as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500 -00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fire
of up to $250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIAJ&idsurance covera.2e verification
I do hereby certify un th pe s ofperjrcry that the inforradtion provi+ded_above ' rue�nd
Si ture: Date:
Phone #:
--
-Official use orily. Do irof write in this area, — to be eornp ed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical I= ector 5. PIumbing Inspect
6. Other - - -. - - -- r
Contact Person: Phone #:
Fitezvieted to: WS
1A - Muoery oaiy ;
RF - RaoI Con:riag
WS - Windows sad Siding
SF- Solid Fuel Burning DcWti
DM- Demolldon aaly
FAZurc to pot Lem a rurmat edition of.Lbe
' State $uilding Code
if dive for revpcatioa of this liccnsc.
$efc in: WVYW.R1 GoYIDQS
]1a <�achusor"; - Dep.11zmcnt of Public S:11
Bourvl ni Ruildial Rcgullntin.s and Standard•
Construction Supervisor Specialty License
Licfr -se: CS St. 99209
Restricted to: WS
VL AMMIR SHEVCHUK
5 OGDEN STREET i
CHI COPEE, MA 01013
Ezoiration: 10112rMli i
(• Huai > <j•.u�T Tr: 992M
i
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i i G Sold, F wAWand aid-UsidW by:.
3g*a:acti Namr. ]Bow; ?u�tr- 41_:i,�� . �1..: ': d'. r:r�. :..',;. � . . ; "' ' ; .?'i'i3a.•At- E�a®e'�ixvices; Tae:
• dtli�`.e:TicmecLCpoE tarrome Stntii es
343$."odd: 'Sie'eat :tblif 2; brcwb., MA 03647 '
Braurb Number. 3I'
99r }�9Fi .yR::# CX!0.9; Coot, 100.. 442T
1_
IttstaHathioaAddresa: ..i ,. ,, ", to
farsiMwse+{s): ; W kfiebG'' F Duinrft i I
�t�: 41
(if drffc+rat from Instalhatton Addro®s) Zip
9 AAdrm (ra' recemw projecc'ebmnau
❑ I DO NOT+wishto rticeiVe m�tk�g e>�s'7&'franl Tti�l44i��+ot'; .' • .
Y1ojeCt�g t me O: Iera i Baed ( "Cu �J, t :4WaEie df. _ `t1iS "lbbWtr 'iOfIdTCSS: , t
cr dTHD nc, "The'Do�t
ffar ttd fr:aisitabbu t� 9 of
bail
a
all ruat Is' deunbod. oo the below and ;on *e � ' �7' ' R; .CA31fi?tct. bar: flue
reference. «Long wick' +mx appfiaable stato•Supplbmant and .1 sy uedof: SuramMty iraeeas od,aa�i ICtiaaBe E�?Jrls (obklecavety.
Job ik oeerrirtrerd o Prodtrds:
,e;,,g:
ciatxts %'covets Y5' ^';..,: t�'
pR.f tf+`u4bwa >oeirt cm ,> � ::. '.:' :
pc3,ri� r tapers pBa:ry flborh � �:
. Pnp, �' Y. DCpvEit�ot' ConbfrlA' >s �ieduei�paYC�, optltliq�:a¢tffiiitl�IgoryFt.,,r .. � j .' ... ., }'. .
11d�ga1► �szl �ert�na�oo�d�it'® niti�aOObfldinl!`tlll,�tp0�f.'' :r. , r. 3'� Customer agrees that,,immkdiatclq• upon completion'.O' 4xlyf4u cy► Chodt�cf; n�' it: c�iebl4la ','.'t~AAap�Et!OF� '
(one for rash Fnoduct' As defined by An individual spce. Sh&O 'aad`psy.>1gY baiei�e des �. 4s appl9da# e,`i1 k: tirsta®er imd�r' Ih+s
Concracr agwes to be jougly ind severely+ oblEgbteil.,and LiatUc hat' U44" .
The Home 17cpar iesevcs tle,right m issue s ar' craze ttY�,e raa# or?p y, iadividaal,�iritiij'} melnded' hemp- at
its di rcredon, if The How Depot or its authoriral Dsi ox o� �i€ gatioam �re'bo u eti ak .
pcoblcaa with the'homc, e„y ;ronmeutal la a sueh rtioli}, agLiestgg,pr7sdd p ,± lioc.,s�ioty priciti8 errnrs.w,bycauae
work required to ctrtpphetc.ttiejat was na inclndcd ia { y {�� d paitmct...:.. > ;
E! = Saullmarrc T6c payment Slrmmary,# •.) J��' *;.`• I 'i 'i 3pdod' ait•6f'gli$ Ct Ct.''seo -faonk the tot&1
Contract amouat and payments required for the dapoeAt's;aadi''€a+il �•by. Psodact'�as" a�gli+�blC) -'` .
NOTICE 1'Of ST.' O
You are ftdtled to a co ike&ia `ofiiie o r'acCs .� Pest eia si¢iv'.Diall '`si t'a '• +Eertifiea4c (iui t .
there is orte Compkt9eta ate for sash As" Prodwd ay .�p•iddtVi�ri� $�cBtiEets} 'em t5a>e pia tat
Is complete,
to the event of torroinatio a of a& Contract, CiADmer. acre" pa p1 T!a'#WW tke eatte oI msterials utb or, ezpeow
and services provided by The Dome 0"wt or Avehorkeld'$e�vlee :P�4vtder :. lt'ie• itate-of seriaY� Adolf, p�las any eater
amounts set forth is this Agreement or allowed aluder' taav: 'Im ] 1AY ! FfI&DI d AMOTSL�T S
OWED TO THE HOME DEPOT F> THE Of = =P,4Y TOR 0T=R 'YAVirlir'•LN'I'•S' MADE, VVITBDUT
LD HTI NGTXIEIIOME DEPOT'S OTHER
REAig.D[ �OD'�OV7eAYOF'SELGI[A�O S
4csentaace and Audwrbstloa Custnma agrees sad understa d& the this !lgreeaasnt La: the entire agseerneut between Customer
c epor with regard to the Products and Imuffiation =vim and sti.mCdea,& prior discussions and agnxmmta, either .
5ral or written, retating to said Produces and IneWhrtian. This Agreement cxmwt bo aasi pad or am a" ertcept by a writing signed
by (Amtomor and The Home DWI- Customer acknowledge# and agrees that catateraer lurs read; =de+Ytande,, votmtmily am" the
terms of and has rem ved a copy of this Agreement
*71
Lis mer's siousaut Date Salm CaLmdusat's SW Date
x TetVhonc No..
"ustomer's Signature Date
5aries Comultam Licen= Me-
CANCELY.ATTON: CUSTOMER bUY CANCEL TBTS {ae 90w
A GkFJEMENT WITHOUT WNALTY OR OBLIGATION
BY ]DELIVERING `GV1f nTF.N NOTICE TO THE HONE I
WEPOT Bit' MIDNIGHT ON THE THIRD BUSII%9S9
DAY AFTER SIGNING THIS AGREEMENT. THE j
STATE SUPPLEMENT ATTACHED HERETO
CONTAINS A FORM TO USE IF ONT IS
31FlECMCALLY 'PRZ D BY LAW IN .
CUSTOMER'S STATE.
NOTICE: ADINTIONAI TI RW AND C Axe, STATtb ON TIIE )MESS A xDARa PAtn' Ot TIM CONTRACT
r.1549 CSC wtNES- 6ramh'Fite Yetlow'�CusfSmet'''PIMO �'Raiea'CtNtsUltet:t'