17C-234 (2) � ^
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' Office »/Investigations
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1 600 Washington Street
BVsA///.41'1 02111
`mr�`�0 wx/wotus»gut,i/i/
\\o/kcm' (,on |osu [uucc A ffiduvit : Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print [ 'blv
�um�(H' /'`o»'',m a`J � |). U �l 7 /7
'" " a « ' w/ / x/ u« �_� _[�_!^~_�l__ T\ L- __ _____________
/
AJ`!rcs- '
--,,.. - .~ � _-_-___-__--____
a,' *xo uxy/"! ,, �[hvck<hcwppnop�v�ohoc
x Type v/ project (rcquired)�
� ���om. 'u,pk.�c,wxh 4� | � 1« m a �uu m/cootmcm/ond| �
~ ^� ' ' h ��Ncw construction
m`i`l.``cc^//`Uxo`k,`,pam'timd�` hovchinx(thesvh'coo�ucmn ' ' � c/»»
� � ,-----1 | am : sole proprietor or partner- |is/cJ on the attached sheet. 7. �] Remodeling
sh9.! have no employees [hcsc sub-contractors have 8. ri Demolition
``^/i,� |"/o`e,` any capacity employees and hovewnrkcn'
/ v. ` �' � U*iiJiog addition addition |�""``,ken. mxlp,ixSur000c cmn m m c
p� �voc
,cq,`.,` :S. — 1 V/c are ucuqmmtimn and iu 10.0 Electrical
' r7 | .m .` !x"vmwurd*ixg»U ^',rk officers have exercised their 11 —1 Plumbing repairs oradditions
m!u/l ! N^ `,o,kcu comp. r'ght^[cxcmPti«x ?,rK16i 12. c-r 1ou[ro ir:
mmzx.-�,c`|uir«!.]
c. �52� "� ''
{) LJ0�ho
ony|"yoes.(Nvw"rkcm' -_ ______ - ____'_--
comp. insurance required.] . ' _______ ______
a`,^m`t.�m./ n,'u�u.,m.^*1 must also fill out the section below showing their workers' wmpomuim, volley information.
/^."`.w.'° , ho submit moaffidavit indicating they arc doing all work and then hire outside mvtr,ci"n must wm`ilo new affidavit indicating such.
'.".`o"u"om^`'xu this box must ^o^ueuo^ additional sheet showing the oun^^rm"sub-contractors and state whether v, not those entities have
""v^`/em m''. wh,^,otrac^.m xv°e *mpioy^^s. they must provide their ■orkcm' coop. pvUcy ,vo`»,,.
__' ___ --
/ till! u/',m//,.r/r i, providing vn/i:r,/' compensation insurance /O/m! rny//urces. 8r/ow is the policy and job site
in formation.
ix,muuc , 'V`xo■ Nome: c ��■- ,_ -_-
,.`|/c■ `.x •//`x^ L'' p:,A,ltA}~ 0'1_ Expiration Date: 1 0
.';` x' aU�33 Lity/Smtc/Zip: 0/8(22_,
Attach a cop\ of the l'orliers' compensation policy declaration page (showing the policy number A nd expiration date).
,o|v,,usu`.'ocovcmgcx/ required under Section Z5/\ or K1GLc. |52 can lead m the imposition n[ criminal penalties v[x
m,.; o|` x` S■ V^.00 and/or one'yco, imprisonment. as well as civil penalties in the /ono ()la STOP WORK ORDER and v 6/
'/'o|`m S25ooUoJav against the violator. Wc advised that m copy of this statement !nay bc forwarded m the Office o[
/x,u/tiLtxtim````fthe D|A for insurance coverage verification.
�=_� . .
/ ^ \ ' hereby ^ under /6, /v/ and penalties (if perjury that the /nfO,vu/on provided above b true and correct.
:S/ _ -_--_{2g1.__ -
r!� -�4���� __- __ __ _
V/ �^ /u/�'ox/r. Do not ^r/� in this area, to he co/nycity tedhy c� or /own official. -
_Purooit/Liccuuun
one):
n| of Health 2. Building Department l [b)f[",,o Clerk f. Electrical inspector 9. Plumbing inspector
xr_
°z �_,.~." Phone #:
_
_
II
SECTION 8 - CONSTRUCTION SERVICES
3.1 Licensee! Construction Supervisor: �
r: Not Applicable ❑
c
Name of LIcn:.e l
Holder J�2.l 1 - Delis l - - ! I
License Number
L 1 (le - 50 _-\-_• • er I.• ' V . • I 5- 0 3-12.
,, Address - Expiration Date
I S ignature � � � � Telephone
, / /
9. Registered Home Improvement Contractor: Not Applicable ❑
:1. / Roof► j 126235
Company Name Registration Number
`.co;cz-, Expiration Date
S u ..anip hn, Ma . 01 C� 3 Telephon�5 7J 3) q ? { 75
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(6))
':Norkers Cant - pensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial c,{ the issuance of the building permit
! Sicned AffirF,\It Attached Yes. .. gi No .. ❑
11. - Home Owner Exemption
,,,,rent exemption I "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) families
:r;., `. to allow such homeowner to engage an individual for hire who dots not possess a license, provided that the owner act2
;es :upervisor. 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. Jr is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
,:,airres. A person who constructs more than one home in a two -near period shall not be considered a
s;:,:h - homeowner' shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall In
rcsponsiblc for all such work performed under thc building permit.
\'; acting Construction Supervisor your presence on the job site will he required Irom time to time, during and upon
,.,,; ,plction of thc work•ior which this permit is issued.
-', :so he advised that with reference to Chapter 152 (Workers Compensation) and Chapter 153 (Liability of Employers to
L:; ployccs for injuries not resulting in Death) of the Massachusetts General Laws Annotated, YQU may be Habit for peraon(s)
oi. hire to perform work for you under this permit.
No undersigned "homeowner" certifies and assumes responsibility for compliance with thc State Building Code, City of
rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
tr Signature attaaked. d— _-- -_ -_ ---
i, ' t;/- 44.41
NW
A
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House J I Addition Replacement Windows Alterations) [ 1 Roofing Ci6
Or Doors (J
Accessory Sl 1g r---]
Demolition t 1 , New Signs (o] Decks (q Siding (01 Other (oJ'
i
6oe` Descn;;t �n of Proposed �
ork
:,iteration of e: sting 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:
.. Use of ;io One Family __ Two Family Olher
. Number o' rooms in each family unit _ Number of Bathrooms
Is there a garage attached?
0 Proposes Square footage of new construction. _ Dimensions
e. Numbe o. stories?
Methoc c, ,neaung? _ Fireplaces or Woodstoves Number of each
Energy Cc:nnservation Compliance Masscheck Energy Compliance form attached?
Type of construction _
Is constru.aion within 100 ft of wetlands? Yes No. Is construction within 100 yr. floodpiain Yes No
, Depth of basement or cellar floor below finished grade
k Will building conform t0 the Building and Zoning regulations? Yes No
Septic Tan, _ City Sewer Private well City water Supply
SECTION la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t i a +A` - (_. (?)0Q- '' -r\ , es Owner Of the subject
property ►,y1� % ' {�
Hereby authon:.e L ' ar Del i Sl e- of R (• c„. -l. . RQof i n9
:o act on my b: half. in all matters r ative to work authorized by this uilding permit application.
' t C he.d • -zz —to
Sig440 Owner. Date
` l
u • ) % ' d' • • ' • • 4 ,• , as Owner /Authorized
I Agent hereby duclare that the statements and information on the foregoing . ..lication are true and accurate, to the best of my knowledge
and belief.
Signed under tree pains and penalties of perjury.
: —,-Malk-- 11 Sit-
Print Name
C �Zs10
I I Signature of Owner/Agent Dale
IP
I S ection 4. ZONING Ail Information Must Be Completed, Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to he filled in by
Building Department
l Sii.e I
r .
F; „„1at;C
Setbacks From
Side 1.: IZ: I.: iZ:
Rear
Il riding Height
HT- - q ag.
uare ( rootage °/,
O - )cn Spree Footage ootage %, .
t I. , t area Hums, bldg !C pavirti
na:%Ctfl t;
. _.
■
II Parking, Spaces
r
II t
L( iUn1C & I Acition)
A Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES 0
IF YES: enter Book Page! 1 and /or Document a
5. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C Do any signs exist on the property? YES 0 NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location:
E WiII 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 O NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
VI ■
City of Northampton Siatu'ilol +-` t ,
Building Department ,E' • . ,
g p Curb C a ;.) t s•
��, 212 Main Street Seer , 4' ', . ' 1, 4 ''' ' ''','°`' '
rl Room 1 00 Wm t> ;} ; ,
Northampton, MA 01060 7 � , or
phone 4 587 -1240 Fax 413- 587 -1272
,..
l ot i Sttie , r e; a�t r l.. + ,', a • ` „.
Other'S... r 'fit; •• t '' , . r
y •
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
3 c.,■ ,S-. Map , Lot Unit
-i- \.b{ 1C. '(_. Zone Overlay District
Elm St. District CB District
SECTION 2 - ROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: Q i
kca cN'e., — n�MO2(1 33 �t, W c,l\ s1/4--- et re n c r ! vela, M CA:2,
Name
�� 1 t ,p
(Print) Current Mailing Address:
_.S.i 1. Ci (7 ) 0"8,9- 4,10
Telepho
Signature
2..`2 Authorized Agent:
-! ly_ — • •
Name (Print) ,/ Current Mailing ..rasa: Cr 1 0
------,,-_ ( q 13) 5 27 - 4 775
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Onty
completed by permit applicant _
1. Building q 0 l r I nicl 4 q 9, `.4 ( (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of .
Construction from (6) ,
3. Plumbing Building Permit Fee
4. MechanicallHVAC)
5. Fire'Proteci
5. Total = (1 2 + 3 + 4 + 5) _ $ `-'t q `ki , p O Check Number J c /!S 7 �/,L
_ f3 5
This Section For Official Use Only
Date
Bonding Perini; Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Dete
•
•
Y
A '
BP- 2010 -1187
GIS #: COMMONWEALTH OF MASSACHUSETTS
t7C 234 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1187
Project # JS- 2010- 001722
Est. Cost: $4975.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 74334
Lot Size(sq. ft.): 26179.56 Owner: DREESZEN CRAIG A & DIANE BOWMA
Zoning: URB(100)/ Applicant: RCI ROOFING
AT: 33 BARDWELL ST
Applicant Address: Phone: Insurance:
6 LINE ST (413) 527 -4775 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON:6/24/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE GARAGE ROOF
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 6/24/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo