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SECTION 5: CONSTRUCTION SERVICES /a
5 I Licensed Construction Supervisor (CSL) ' t _ • _ /i z_
ci: k, (_._c . L (� o •
Lei Z License Number Expiration Date I r – c:; Name a* - Heler List CSL Type (see below) r �Lr ��..
dr s Type Description
Vk–frtAk . lna. U Unrestricted (up to 35,000 Cu. Ft.)
Signature R Restricted l &2 Family Dwelling
L` M Masonry Only
C° RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 egistered H Improvement r (f.0
Home Improvemt ContractoC) / //
LOZ,( i / Tv P •&,,,;" -%�„€ 1 L LB. _. f C . -4-
HIC omo Name or FCC Registrant Namy Registration Numperr ,,
Addr °ss c �,� �
, -"ti i�," �, ( 1/3 3),C, -) (. Expiriation Date
Signature ,.. Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
i
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 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BLILD' ING PERMIT •
I, •.,c . .
y.,(h -'‘..1 ( \ \Gg ry 4 ' , as Owner of the subject property hereby
authorize ! C:� 1- N,N1A- --s, . t/1 \,,\ . 4-'4' y to act on my behalf, in all matters
relative to work author eid by this building permit application.
21, AO)
Signature owner ' 7 Date
! SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I - Orel C-'v'` LA t ' I `' , as Owner or Authorized Agent hereby declare
that the statements and information 41 tae foregoing application are true and accurate, to the best of my knowledge and
behalf. ,
Print ,�, d ,,,
:.. i / c/
Signature of Owner or Autho d Agent D e
{Signed under the pains and penalties of rjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5,-respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open I
3. '`Total Project Square Footage" may be substituted for "Total Project Cost"
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E1 Siding [0] Other [O]
Brief Description of Proposed
Work: 'Ot°,,c `tee .3... -t " { , 1I IA t rv5 ;VN t Sf )Vs.. i 4 (. C A Al r
Alteration of existing bedroom Yes ; No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ''y 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 ' 4^
I, G \- ,,.4 DU (,V1(:} v-\.. , as Owner of the subject
property
hereby authorize . c..) 1 �R � i � ` t r iry N
`._ -
to act on my behalf, in all-hitters relative to work authorized by this bu permit application.
1 rt. )-•,2 , -� 1 ji G t f,,, ,,, , _. __..._. // f/
Signature of dwner Date
I, -\ I N \CA 7 _ V,_ C^, W2 as Owner /Authorized
0 el_ , 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 '
Signat1
Owne r /Agent 1 Date
Department use only
RECEI"ED City of Northampton Status of Permit:
Building Department Curb 0ut/DrivewayPermit
212 Main Street Sewer /Septic Availability
JAN 2.3 20 Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
c „ oN a 41 587 -1240 Fax 413- 587 -1272 PIOUS to 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
P1 ■l () 630 VA Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1.t Cti�c (` R_ ��t 3 ljtr ��, ,;�� bt u ;,
Name (Prirft) Current Mailing Address:
1 -5201
It 41
1;c ,_C .__ . . Telephone
Signa ure
2.2 Authorized Agent:
Name (Pr' Current Ma ing Address: ' V
/2/ /
Signature f Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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 = (1 + 2 + 3 + 4 + 5) ' Check Number L5W
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0671
APPLICANT /CONTACT PERSON MARK LANTZ
ADDRESS/PHONE 74 LYMAN RD NORTHAMPTON (413) 320 -7611
PROPERTY LOCATION 243 AUDUBON RD
MAP 05 PARCEL 042 001 ZONE RR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
—
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out J / `55�
Fee Paid /
Typeof Construction: AIR SEAL & ADD ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 102169
3 sets of Plans / Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF TION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
243 AUDUBON RD BP -2012 -0671
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 042 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0671
Project # JS- 2012 - 001158
Est. Cost: $2200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 51836.40 Owner: DUCHARME LOIS B & RAYMOND JR
Zoning: RR(100)/ Applicant: MARK LANTZ
AT: 243 AUDUBON RD
Applicant Address: Phone: Insurance:
74 LYMAN RD (413) 320 -7611 WC
NORTHAMPTON MAO 1060 ISSUED ON:1/25/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL & ADD ATTIC INSULATION
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 1/25/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner