38B-179 (2) SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ,r ✓! Not Applicable ❑
Name of License Holder : ?1-I � t f V'4AG.r `- z )4- 7 S'
License Number
- S E- aivLc,E C t ()t 1 ti ,09
Address Expiration Date
■
Signature Telephone
9. Registered: Home: Improvement Contractor: Not Applicable ❑
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 ❑
11. . Home Owner Exemption
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
SECTION 5 DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing ❑
Or Doors 1]
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [0]
Wor Description of opose/ si- Y ' Y I _ K ?c Z ' * i
Work: Zb 2s} i Hcr► FiAmi� � i? iiArit iQ e
Alteration of existing bedroom Yes No Adding new bedroom 1 Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6a. if New house and or addition t existing housing. complete the following:
a. Use of building : One Family V Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? D pt
S r cit:. 4 ec
d. Proposed Square footage of new construction. L ri ° Arc s ZzY Dimensions 2 U ��
e. Number of stories? �---
f. Method of heating? 6; As/ i t -A -tit Fireplaces or Woodstoves P Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction 2-
i. Is construction within 100 ft. of wetlands? Yes V No. Is construction within 100 yr. floodplain Yes Vigo
j. Depth of basement or cellar floor below finished grade f
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply V
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
, 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
Signature of Owner /Agent Date
i r rf t/ t
City of Northampton Stus'af Penx*
Building Department Curb :�Dr yPer
212 Main Street e�il�err /Septa i vatl hi p r X
Room 100 Water/WeltAv lab!
Northampton, MA 01060 Two Sets of St uct t4Pleri n .
phone 413 587 - 1240 Fax 413 587 - 1272 PlotI$te pans,
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TI/V0 FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
2 ) - Map l o t Unit
N • ►Z zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
6€. e tom �4-� �t 1 c ra
Name (Print � Current Mailing Address:
� �- — I 2 Z Q (
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature 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 j coo . (b) Estimated
Construction from (6) of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection '
6. Total= (1 +2 +3 +4 +5) 4-6 Check Number /et 336
iClitirAtO This Section for Official Use Only
Building ermit Number: I s
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0399
APPLICANT /CONTACT PERSON ROBERT WALKER
ADDRESS /PHONE 36 Service Center NORTHAMPTON (413) 584 -1224
PROPERTY LOCATION 13 FORT ST
MAP 38B PARCEL 179 001 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 j0 57 3i6
Typeof Construction: CONSTRUCT REAR 20 X 24 ADDITION(1ST FLR FAM RM /ENTRY /BATH,2ND FLR
BEDROOM)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 107004
3 sets of Plans / Plot Plan „71Pael fr E497111(3
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
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.
•
" BP- 2010 -0399
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 179 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2010 -0399
Project # JS- 2009 - 001152
Est. Cost: $48000.00
Fee: $336.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group: ROBERT WALKER 034783
Lot Size(sq. ft.): 4356.00 Owner: WALKER ROBERT J
Zoning: URB(100)/ Applicant: ROBERT WALKER
AT: 13 FORT ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584 -1224 Workers
Compensation
NORTHAMPTONMAO1060 ISSUED ON:11/9/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT REAR 20 X 24 ADDITION(1 ST
FLR FAM RM /ENTRY /BATH,2ND FLR 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 11/9/2009 0:00:00 $336.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo