38A-006 (2) • ' . , ,
• ,.
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. ,. The Cominonweatith ofilfassachusetts
• r.r.ezz.:-----• Department of Induitiint.rfecidents . .
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'-' - 1.311i0== - : :•:( • Office of Inims • •
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600 Washington Street
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Boston, Ml 02111
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. www.rnass.(vvidia
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Workers' Compensation Insurance Affidavit Btulders/ContractorsiElectricians/Plun3bers
Applicant Information . _ - . Please Print Legillv
Name (BusinesilOrgtOiation(ctividaz: . --- cfft - C. KA t: , --k- A-
- Address: el, L A-LL te._ E. (-- s
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•
City/State/Zip: N1 c . - - - Phoneg: 4 5 5 7(07 -
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Are you an employer?.Cher.k the appropriatebox: . - - • - Type - of prOject (required): .
1.0 I am a employer with .. 4., 0 I am a general Contractor and I
6. 0 New coistruction
have hired the sub-contractors
employees (full and/or part-time).
2D I am a sole proprietec r- . listed on theattached sheet 7- Erilmmodeling • .
• ship:and have zin emplo-yets These sub-centracturs have s 0 D ) lid ati . • • -
working for me in any capacity . ewloirc.gg-.....4P4.12Ave worker-a' . 9 j , - .-- - ..-- . - -
[No worbers' comp-. insurance - _. comp_insm:Mcil-:. .. ._
• eeqwle'l 5. 0 We * a corporation and its 10.0 Pectricrd repairs or adcfnions
3.1,2 • - -
I am a homeowner doing all work . officers haiefrreised their . ILO Pluinbini repairs or additions
myself [No workers' eomp. - ries Of exemption per MGL r—t
12.0
insurance required.) t ' • : p. 152, *44); and ; we have Do • - - -. .
• 13 (*ice - • .
• - einployees. [Na workers'. -
•
- *Any applicant4hat cheeks-box #1= mustadsa fill autthe section heiatvahowing their:Wade:re egrapeasation parteyirdamatdam ' •
: t Hataecronai arbo subialt tics affitia they are doing ail work and then. hir' e outside conhaitors must =teak aneataffidavilindicalieg such.
tpxonciars that cheick this box raitstattached an athrttional sleet sboying the name aft sub-contractors and atatc whetherar awhasectrtities have • . •
erisOloyees. 'rate sab . htie einpktyeet, they raustgovide thcir vaidceis" eomp.,paTicyaumber.
Inns an amp! Yyer tha isilinviang wearers' compensation insurance for thy en:player= BeInn is the policy Ind Joh- sit' e
information. . . • • . . •
Insurance Company Nam= . -- . - • - . - . - - - - . - — . . • - • .
• . • - . • . -. , . .. • "-- , . . • " .
Policy # or Self-iris Lic.-#: ' • • - • -. - ; Expiration Data: - ' .: : . - •
. . - - -- . - - - • ---- - - - - -- ' . ,-. - - -
?th Site Address: " - . : • . ''''• - CItyfStatelZipf
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Attach a Calq of the Yrork,is!:50111rYcTde.c4lrafrn1,16-(s1K_F.,9*th policy ***!.114::e2Rirityin day).
Failure. M sect= • eirverate":ii reiiiiiilt iliWe.StietiattiATTMGVe:•152 rein:Ito' the iiiipo iiiiiiiri4aiiiiirigiiiiiat*auf a
fine zip 10 51,50000 and/or one-year impriscormen4 as well as Civil penalties m the from of STOP WOBJE ,-0.12DER. and a fine .
' of up to 525000 a day against the violator. - Be advised that a coyyO statemem maybe folisraideiliOil:e.•-przi
ifilistartit. - --.. - ---- 7 - 7:. ..- ' .-.,:: -.- -:-.7,-----1.-::....7L-J.L.:.....=.,- .
rakeriiii:c:atiiiT 10;4 die Pains - ;1 3 ;d: Porga 46441--- if-Pei:thlaitheilifin4IrtivillEol-afii*:ict.:--‘._:.__
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1 si ;,-;, ice only. Do not writ' e rn is arta, In be cornp -er7 by city or tou4s offirtal •
. - .
' .City or Town: . . - •- - - PermitfLicense # • - • , ,..
- Issuing Authority (circle one): .
. :1. Beard of Health 2. Building Department 3. City/Town Clerk 4. Blectrical,InSpector 5. Plumbing Inspector -
6. Other
.
. •
Contact Person: Phone #: - . .
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The Commonwealth of Massachusetts
,_ =6.=...- ....... Department of Industried Aecidents. • .k r4 l ir.
•
•,:, r....z.:--511,. : • Office of Inivstigations •
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600 Washington Street
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Boston, MA 02111
"i 'l • - , WWW.mass grov/dia
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-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers ... .
AAplicant Information Please Print Legibly
Istmcliftr
Name (Businesi onfind
ADrsanizatiiviclual) 6
: ,,,_,.../„_.,Q n . •,.:_.•, •
• :
.:,.,:..
- . Address: 94' 3 fl
City/State/Zip: rb -M4k_. Phone.#: 3r ....7 .
Are ou an employer? Check the appropriate box: - -Type of project (required): /
• On: I am a employer with 4. El I am a general contractor and I
6. 0 New construction u
employees (full ancl/or part-ticoe).
have hired the sub-contractors
2_0 lath a sole proprietor orparmer- listed on the attached sheet. 7- 12
• shke and have no .iployees These sub-contractors have -8. 0 De.nielhibn. -
working for me manly capacity emicirPgr_grociliaVe vArirters 9: 0.1ititildirliaAira' En
[Ne workers' con insurance - _ comp..insunincel:.. _ _..„._
5. 0 We are a corporation arid its 10.11 Illocnissi repairs or additions
- 1 01 am a homeowner doing all work olEcen hai4xethised,. . their . 11.0 Plumbing repairs or additions
myself [No workers' comp. . right of exemption per MGL 12.0 Roof repairs
insurance required.] t • . c:. 152, §1(4), and we have no .
. . . employees: [No wedcers' 13• 0 Other - -
-
• . - • . comp insurance reqUired.1 . • : .
- "Any applicant that checks box anaist also fin out the section tdowahowing their compensation policy information- : , •,-:. .
- t}01 :who submit' this affidivitincliCating they are doing all work and then hire outside contra:tors =1st =lank a aew affidavit indicadag such.
Icontractols that check this box naistattached an tattlitional sheet showing tonal= of the snii-contractols aid State whetherornotthose-entitics have -
onplOyees. If the sub-contractorshrie employees, they matt provide their workeis!" comp policy amber. • : - , : . ..-: ' :: - .
V . lam an employer tiurt is provirling workers'Compensation iitstwancefor my employees. Below is tire policy andjob site
information.
Insurance Co m p a ny Name: 44.1„.1V1
Pelicy # or 5elf-ins. Lie.- #: V ' C- ‘ Co S 6 0 R0 1 • , Expiration Date 4C 1.6---r 1/ .
Job Site Address: 4 Lz t..) re. 1,- ' Crty/StateiZip:4
Attach a copy of the workers' compensation policy declaration page (showing the policy number 9.14expizatictu date).
Failure kr secure coverage as reqiiifed inicrefretto 152cidi lead lei the ifirposiiiio" n`' -iir-cJi:-1;fin iiiiki of a
fine up to $umo() and/or one-year ireprisonmen4 as well as Civil penalties in the form of; STOP WORK-ORDER and a fine
' of tii $259.00 a day against the violator.. Be _advised that a copy of this statenient may be forWardettnithe Offfee Of
IniteatinTitions ElftheDIA . --: - 7 7 . . :
lila liWaiii iindirtii7::.andpenaitthsojiirfrioithrifthe infinnadoniwOrtaiirri a :=.
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s6iiiitz:e: 1 .44%4 f i At ••.. S' - -- - ::-.-• 7 : : - - 7:6 - W`7.- g.)—ye, . •. V •
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pp#• 1, 74 - ...- , :::- 7 ' 7 . - . • •. V
I - Oi . ''', use only. Do not write in this arra, to be comp , ,, by city or toWn OfriciaL
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or Town: ' Permit/License # ' •
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Issuing Authority (circle one):
. Beard of Health 2. Building Department 3. Cityffown Clerk 4. Electrical,Inspector 5. Plumbing Inspector
6. Other .
Contact Person: Phone #: .
July 4, 2010
„ 1 t_ Lu
TO: Lo'iis Hasbrouck
FR: Jackie Duda
RE: Building permit 56 Laurel St, Northampton
I contacted your office recently to determine the status of the application for a building permit I applied for on
June 5, and was told I must submit the Workers' Compensation forms.
In the time since I have applied for the permit I have obtained the services of Gerry Archambault to guide me
on the building code. I plan to hire him to do some framing that is required by the code, according to Gerry.
I am doing the balance of the work, and if that changes, I will submit Workers' Compensation forms for other
workers. Because I am doing some of the work, the woman in your office informs me that I must also sign a
Workers' Compensation form, so a form is enclosed for me also.
I will be away next week so if you call me I will not be able to return your call right away.
Otherwise, I look forward to the building permit arriving in my mail box upon my return.
Thank you.
June 5, 2010
TO: Lou Hasbrook, Building Inspector
FR: Jackie Duda, 56 Laurel St., Northampton
RE: Building and electrical permits
Enclosed are the permit application for electrical work and alteration of the second floor bedroom at my home.
I plan to remove plaster and lath from the walls and ceiling, rewire the existing old electrical service, install
hard -wired smoke /CO alarms, repair the chimney that goes through the bedroom while the ceiling is removed,
and replace the bedroom door. An energy audit was done earlier in the year and I hope to have cellulose
insulation blown into the walls and ceiling. The electrician is Steve Keyes; I have not chosen the carpenter as
yet. As the homeowner, I am acting as the construction supervisor.
Per your instructions, I will call for a building inspection when the electrical is in and signed off, prior to and
after the insulation is installed, and after all other work is done with the exception of trim/paint /finish work.
Enclosed is a check in the amount of $120: $65 for the electrical permit, and $55 for the building permit, the
amounts were taken from the Northampton webpage. If it is incorrect, please call me and I will submit the
difference immediately. Home evenings: 586 -5767; Work daytime: 268 -8404.
Thank you for your help on the phone also.
O l S Pc (Q 0 R
r Lo er. ce (J 0 2
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
i in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, Jf t-tl yhl 1) �t _ understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date te1e -- CAS /2 b!0
Address of work
location Sfv 1-44,04-6L Sr
Ai 04- 771-4.7 Avi-
. The Commonwealth opfassachusetts
Department of Industrial Accidents
P k =••••` ." -- si
Office of Investigations
f.2 j- -----/'
600 Washington Street
%, =.7.19......, ,..
Boston, MA 02111
www.mass.gov/dia
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-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly --:
Name (BusinesS/Organiiation/Individual):
• Address:
City/State/Zip: - Phone.#:
Are you an employer? Check the appropriate box: •Type of project (required): 17 I
1.0 I am a employer with 4. 0 I am a general contractor and I
6. [1 NOW construction
have hired the sub-contractors
employees (full and/or part-time
listed on the attached sheet 7. 0 Remodeling
2. 0 I aro. a sole proprietor or partner-
ship and have no. employees These sub-contractors have. 8. 0 Demolition •
epiployee.s and have workers'
working for me in any capacity. 9: 0 Building additiOn
[No workers' comp. insurance
10.0 Electrical repairs or additions 5. 0 We are a corporation and its
required4 -
3. 0 I am a homeowner doing all work officers haVe4xercised their . 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 Roof repaiis . -
insurance requirecLJ t • c. 152, §l(4), and we have no
0
employees. [No workers' 13. Other
coin Insurance' required.) -
_
*Any applicant that checks box #I must also fill out the section below showing their-workers' compensation policy information.
1. Homeownera who submit this affidaVit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:contractors that check this box must attached an additional sheet showing the name of the sub and state whetherornotthose entities have
employees. If the sub-contractors have employeeS, they mustprovide their workers comp policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: . • - -
Policy # or Self-ins. Lic. #: . Expiration Date: - • .
• . .
Joh Site Address: : . City/StatzrZip:*
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage, as required Mid& SeCtiiiii25A 152 can lead to the ii±q5ositibii of Criroin4 Penalties of a
fine up to 51,500.00 and/or one-year imprisonme* as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $25000 a day against die violator Be advised that a copy of this statement limy be forwarded to the 0 of
. - 7 -4 777 7,777,17._,_7
7 -.........._,____,-__„„..,__,.......,_.
_ 1dd hereby certify under the pains and penalties ofpedlaythat the infOrmationprovididabove_andiop-pet _
. _ . .
Signature: ' Date: ,
. . .
Phone # ,
.
: - Off - wird use only. Do not write in this area, to be completed by city or townofficial
City or Town: ". Permit/License # .
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
e
8.1 Licensed Construction Supery isor: Not Applicable
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
r1P .gam , Not Applicable licable ❑
Not
Company Name Registration Number
Address 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 ❑
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 building 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 95,x-ctr'`jtjy1011 1
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[j Siding [D] Other [pi
Brief I sription of Proposed e
c
Wo 0 errov`6 r I�.s e.- Imo. R-,- -" zr■ck ,., 6K j .S i-.Re._ , (ns via* , rev./ire, 1 ScnwKQ
Alteration of existing bedroom Yes ''' Adding new bedroom Yes ✓ No 4
Attached Narrative Renovating unfinished basement Yes ✓ No S cee....alk
Plans Attached Roll - Sheet - Vie.- c,i--icE --Q
sa IfNewe house an e § chink existtififhrriiu sing comf plete t re'�fo#iawluir a: N�(k �� L
a. Use of building : One Family Two Family Other
b. Number of rooms in each family uni . Number of Bathrooms
c. Is there a garage attached? AS4
d. Proposed Square footage of new constructs • . Dimensions
e. Number of stories? a-
f. Method of heating? g t'st fuez it ,4-- 6011 Fireplaces or Woodstoves Number of each
g. Energy Conservation Co lance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes o. 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 b is building p- it application.
Signature of Owner Date
I TAC. U. t I U ■4 I) ...LOA , 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.
Print Name 6 $" 2,010
1 :-,.d .1 - 1-r+
Signal- of . ner /Age' Date
,
• -
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
NO CAAleS Existing Proposed Required by Zoning
This column to be filled in by
e tigd $ C4 Building Department
Lot Size I t 1S �' , /� ; x
Frontage ` I £
Setbacks Front FT-VI F261 1
Side L:$ i 0 1 R: /° 1 L: _._,.._ R:
Rear sir i .- __.._
Building Height L .___.___
Bldg. Square Footage jY14 I 3 % Mel I I
Open Space Footage %
(Lot area minus bldg & paved L I I ... s
parking)
# of Parking Spaces _ ,,___J
Fill: 1 ,� i I
(volume & Location) la
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ef DONT KNOW 0 YES 0
IF YES, date issued:1 i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I t Pagel and /or Document #1
B. Does the site contain a brook, body of water or wetlands? NO d DONT KNOW Q YES 0
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 0 NO
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
IF YES, describe size, type and location: I
I
E. Will the construction activity disturb (clearing, grading, exca ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
III,
City of Northampton
Building Department
� 212 Main Street
`� ` Room 100
\ ' ■ Northa pton, MA 01060
phone 41 -587 -1240 Fax 413- 587 -1272 fl�
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
c6, LA- L S Map : - Lai ,, Unit
tQ 1 "l' Zone OverlayDrstrlct
Ehn St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
711-C-0 u f✓ l y N b %A-bit ad) 0 3 q f'/ tt J2-Cnte. G1t3L+.Z
Name (Print) Current Mailing Address:
� S_ 7f6 7
Telephone
Signal
2.2 Authorized Me :
N /A- c tai E` /i-> Prei t44
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
(a) Building Permit Fee
1. Building
S
2. Electrical (b) Estimated Total Cost of
°L �"�' C C Construction from (6)
3. Plumbing .. Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection Vet. OC
6. Total= (1 +2 +3 +4 +5) I yfj OC. Cc) Check Number �{ —
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner /Inspector of Buildings Date
•
•
•
File # BP- 2010 -1171
APPLICANT /CONTACT PERSON DUDA JACQUELYN
ADDRESS/PHONE P 0 BOX 60392 FLORENCE (413) 586 -5767 O
PROPERTY LOCATION 56 LAUREL ST
MAP 38A PARCEL 006 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: RENOVATE BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
Demolition Delay
41".ej 6 1.1D. 0
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.
4
ki -�:° 14 V. BP- 2010 -1171
GIS #: COMMONWEALTH OF MASSACHUSETTS
IWO 8A 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 -1171
Project # JS- 2010- 001707
Est. Cost: $4300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 6882.48 Owner: DUDA JACQUELYN
Zoning: URB(100)/ Applicant: DUDA JACQUELYN
AT: 56 LAUREL ST
Applicant Address: Phone: Insurance:
P 0 BOX 60392 (413) 586 -5767 ()
FLORENCEMA01062 -0392 ISSUED ON:6/23/2 01 0 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE BEDROOM
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 6/23/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo