25A-022 (2) SECTION 8 - CONSTRUCTION SERVICES
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8.1 Licensed Construction Supervisor: Not ,
Name of License Holder
Loers Number
I Address Expiration -Date
Siunature
9 Registered Home Improvement Contractor: No Apoliparie
Company Name Registration Numuei
Attoress Expiration Date
Telephone
SECTION 10- WORKERS COMPENSATION INSURANCE AFFIDAVIT c, 152, § 25C(5))
'VVorkers Compensation Insurance affidavit must be completed and submitted with this application Failure to provide this affidavit will result
in the denial of the isst./anoe of the buiidirip permit
Signed Affidavit Attached Yes ___ 0 No „
11. - Home Owner Exemption
The current csemption for - horneettners - as eNtended to include Owner-occupied 1)% ellino5 of One ( 1 Or ttiir ) it
and to allow such homeowner Li erigisee tin indivldual for hire who does riOt pOSSCS5 o license. provided that the owner acts
0. t.upen isar. ( 780, Sixth Edition Section 108.33.1.
74,7mition of Homeowner: Person (s) utio own a part:el of and on tshiell Me"she resides Cr intends to reside, CO v, Mich there
is, or is intended to be a one or tuo ramify dweling, ;fruit or tic:at:heti structures tisteosse to sud ). ace and or farm
structures. person who constructs more than one home in a twv-Vear perin4 511.at mit lee eutzt:ifffti!
Such - norrisN.Avnia - i:h..511.s.uhrnit to the Buikting Official. on a form acteptabl: to the Building Official, that he/she shall he
1 tut the building permit.
As actim.: Construction Stipenise+ piserK, on the job site s& ill bie required from time to time,. duriatt and upon
completion of the work for ubitth ;s is,sut%1
Also
he advised that with rcfescrice to Chapter 152 flk'oriters' Compensation) and Chapter 153 Labilii tit Employers to
Employ for irtjuries not rettulting in Death) of the1vtassachusetts (loner Laws Annotated, you may be liable for persons)
oe hire to perform work for yclu under this permit
'lie undersigned - homeowner - certifies and assumes for oroce wt th Sta!„: Ruitdotg Cride, ( of
Northampton Ordinances, 'roc arid Local ZoninL2,l,„tutfani ` 1 ..P; )), ftmh.,e-tf-ti-1
Homeowner Signature ';',7k-
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
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New House 1 Addition [ Replacement Windows ' Alteration(s) I - Roofing ... l
i Or Doors E3
Accessory Bldg 1 71 Demolition 71 New Slone F',0] Decks fa] Siding ID, Other [C3l
Boot Description o Proposed --,'' ll , l. " - - " ,, r l ll'Th- , h-' I L. --1 ,. - '1 . ll"E'
' , i' : ' ,- :` ' ,, :::- ' ' ' ,,
1
Alteration of ex:sting bedroom ves No Ado=nd new bed oar Yes No
Attached NarratIve Renovating unfi niched basement Yes N
Plans Attached Roll - Set
6a. If New house and or addition to existing housing, complete the following.
a Use &building - One Family Two Family Other
5 Number of mama in each family umt: Number of Bathrooms
1 a is there a garace ottacherP 1
i d Proposed Square footage of new construction Dimensions
e Number of stories?
I f Method of heating? Fireplaces or Woodstoues Number of each
g Energy Conservation Compliance. Masscheck Energy Comp lance form attached'?
I
h. Type of construction
1
Is construction within 100 ft. of wetlands? Yes No Is construction within 100 yr. floodolain Yes No
j. Depth of basement or cellar floor below finished erode
1 .
1 k. Will balding conform to the Buliding and Zoning re,nukatlone? Yes No
I i Septic Tank City Sewer Private welt City water Supple
i
I
SECTION 7'a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Ownenof 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
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I.
I e r Y ..;''.''' 1 4-1 as OwneilAuthorized
Agent hereby deciareinat the statements and information on the foregoing application are true and accurate fo1he-bes knowledge
and belief
I
Signed under the pains and penalties of penury
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; b f frr Li j ,.,-j--- 1., ,i., l'c hi,i,
Pica Nove ,....../ /- / 7/
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Signature at * -, eriAgent Date I
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I Section 4, ZONING Ai: Irlfouriation must Be ConQleted. Pcrrrnt Can Be Denied Duc T incomplete infc.)rmation
\isting Proposed Re,p;red h\ Zoning
'71 ri;ieJ
r. Depa:t
L;./1 Size
1
Seti Fronj
Side .
Rear
Buidinq Height
Bldg.. Square Foota52,e
Open Spa,-E F ootaur
n 1,4!kmp.,
of Parking Spaces
Fill:
A. Has a Special. Permit,/ Variance/Finding ever been issued for/on the site?
NO CY DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained
0 , 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 0
IF YES, describe size, type ard location:
E WI the construction activity distirb (clearing, gradinp, excavation, or filing) over acre or is It part of a common plan
that wi I disturb over 1 acre?
YES 0 NO
17 YES, then a Northampton Storm sNater Management Pemir, from the DPW is relwreO
_._.1._... _
Department use only
C of Northampton Status of Permit:
B 'Iding Department Curb Cut'Onveway Permit
PPR 2 B Z° 12
: -..2 Main Street Sewer/Septic AVElitability
Room 100 - IftiaterNVell Availability
wit4GINV • ; mplon, MA 01060 Two Sets of Structural Plans_
:' NOfatie '„''''. i n e 413 Fax 413 - Plovaite Pans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 . SITE INFORMATION i
This section to be completed by office
11 Property Address' ,
7 f
Map Lot Unit
J :i // ''' .,.. /-
, e Zone Overlay District
1 1
1 /: Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
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2.1 Owner of Record: i
1 ---- 1 - 1
., r - , ..4 4
Nar ,,,,_ ,'' / ; } Current 'fla ring Apdr9s5. i c,.. _, - ._,,
I
' f, i f TelePriole )
Signature
2.2 Authorized Agent;
Name cPrint) Current Wailing Address,
Signature Teiephone
SECTION 3 -,ESTIMATED CONSTRUCTION COSTS
1
Item Estimated Cost (Dollars) to be Official Use Orly
completed by Den aPplicant
1 Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3, Plumbing Building Permit Fee
4 Mechanical (HVACI
5. Fire Protection
6. Total = (1 + 2 + 3 -.- 4 4 - 5) c -) Y 0 3
I Check Number m 0 c 1 9 9 y7 —C
This Section For Official Use Only
Date
Building Permit Number issued:
Signature c .. .., - _
Building Commissionerfinspecty of Buildings Date
51 MARSHALL ST BP- 2012 -0837
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 022 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0837
Project # JS- 2012 - 001409
Est. Cost: $57500.00
Fee: $345.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 6621.12 Owner: FILKOSKI JOHN J & SOPHIE A & FILKOSKI HENRY
Zoning: URB(100)/ Applicant: FILKOSKI JOHN J & SOPHIE A & FILKOSKI HENRY
AT: 51 MARSHALL ST
Applicant Address: Phone: Insurance:
P 0 BOX 933 (239) 793 -7100 0
HADLEYMA01035 - 0933 ISSUED ON: 3/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE KITCH,BATH,REPLACE STAIR
TREADS& RAILS,REPLACE INT &EXT DOORS & INSULATE CELLAR
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 3/28/2012 0:00:00 $345.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner