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1.) EPARTMC ITT 01 EU! LD170 INSPECTIONS
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212 Main Strcct • Municipal Building
Northanptol), Mass 01060
WORKERS caryLPENsATIoN i AFFID A VI T
ancloal lac of
7 0 E a _ ehaty7pfor) n ( iv/3 (c_)
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/ 56r7 -o 763
C;by coJ f-110. r);117123
: an employ:: provIcill c_•oinponsacion :C7
OCS \ on ii job
rOct LC - cy 014 -o
(I r cur-anal a rty) ) Data)
LLE,1 a sole prourietor, 2eneral (circle one) and
00=acicis e0 below coEnDens-‘21:orl
of Con:to:
of l :a ncc 2le)
1.:_u of Con:ractor) Clias Nurns)
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r of en LL, WOcy's
. a co-py of tho..g of C;f5c, of
covc vrcj th_tt fir.41urc to 7'7: 2. A if I !.) 2 call I c...d irnrosaio:,
11, o f u p to SI CK 00 .7: o,r,,,2 r.• clvtl ^,-11.1.1t1CZ rinln CS Sk 17.-i •
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SECTION 8 - CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
1 .- { Name of License Holder : ' C i l am I ( Q 9
License Number
/ 7 0 rCiNCi, - F L 0/ o) I l a $- 0 6
Address Expiration Date
/
9 -- 8 •
'gnature Telephone
:x3�Re • �sfered= Home�m rovd'ment�ontrac�`o � . ?.� :: °- , , .: � ��-�.. °'"- �,�,�"�- Not Applicable ❑
4 1 — e l - h l tcticier C rrCer
Company Name Registration er
17 rnhG -
Address Expiration D a _ I 7
t horn p r) , /V/74 /74 Telephone 1L 5S
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 ❑
1fl omeneE•grip
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 - vear 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
r
1
SECTION 5- DESCRIPTION OF- PROPOSED WORK (check all'applicable)
New House fl] Addition Q , Replacement Windows Alteration(s) ( ( Roofing
Or Doors C7
Accessory Bldg. n Demolition New Signs [111] Decks [p Siding [O] Other [0]
Brief DeAcri tion of Proposed
Work: t X-PN10 5 b `t L tY l t /19 S al y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a =IfSNevr hoase ifaG,Vct'di#Zi`' atexist�nq h Usin omplete the owt q:
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-
, as Owner of the subject
property
hereby authorize
to act on my behalf, in at matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ere / r (rl f /e.. ' , as Owner /Authorized
Agent hereby de r e 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.
1.6/\
Pri Na - A
ignature •f ner /Agent Date
Section 4. ZONING All Informatioh Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size i I
Frontage l I 1 ! I
Setbacks Front o
Side L: R:' ! L:' R:l
Rear
!
Building Height
I ,
Bldg. Square Footage % +
Open Space Footage ---1 % r--
(Lot area minus bldg & paved ;_____f i i I 1 I l
parking)
r--
# of Parking Spaces
Fill: ' j
(volume& Location) 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES Q
IF YES: enter Book i Page, and /or Document #j
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
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 and location:
E. Will 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 0 ,- NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t
City of Northampton r ti,'g fl � -
Building Department rd y� § n Rt - .¢
212 Main Street � i s i = �. .. i � - s
Room 100 �' F' l�A ,4 �t.•+ i ' - � i
Northampton, MA 01060 � @ ,.mss ..,4.A
hone 413- 587 -1240 Fax 413- 587 -1272 P o i -_
v dRf ,_. - -,':'' »,_ n ** �i.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 1 ~.
1.1 Property Address: t This section to b completed y office
. e I o-A- ��9 ( 1 c Map � . init
Z one ' � , , .44 � Overlaybistrict.
, x '9 a'y of ,ivzt . m Aa ^ 1 , � �k
v Eltr St. District a A ' , I ,h., . t CB lstr ' .
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
1,4_41,1'5 AA-6 i ii + ' --
2 .1 Owner of Rec •
N I t74 ° Gtr r�� - o-m-tat4 r _./
N-me (Print . 1 Current Mailin Ad res
Telephone
Ign. r
. uthorized Agent: r
Ike r . -{ -k. ct A Ito") 1 7 C Eck. 517 C ttti1 , Alu.vr 437
Name (Pr t) j ' A / Current Mailing Address:
�- 7rS s ot7— 8 3'6
2 -P7
ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ) 3 6i .. (a) Building Permit Fee 4 17 5-A 00
/>
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 5` 91`4
This'Section For Official' Use Only
Building Permit Number. IIsssued:
Signature: r
i
Building Commissioner /Inspector of Buildings Date
f
File # BP- 2006 -0539
APPLICANT /CONTACT PERSON KEITH HAMILTON
ADDRESS/PHONE 17 ORCHARD ST EASTHAMPTON (413) 587 -0763 Q
PRO' t. , <°.a ' ' {sx ; o ,
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 6 J $
Tvpeof Construction: DEMOLISH 2.5 STORY LANDING & STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074129
3 sets of Plans / Plot Plan
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
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.