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31A-137 ._ , ,..- • - - 1 . k ys, ,, • \ -- .......--> _,-- .„--- ,--- — _______----------------- \ .-------N bxZ \ e 411 \ 0 _......„------- N\ N N - N N , / / c-''4-kk' ( .7 - 0/ 8x7 N „ , 0 t • - •* ' '.w4 \ •- • *kx44.'° ori m . ey1/4)* csi . WI Cir 11.1 4 ...c., 44.PC\ kk All' a tY S \.1 \rit • Pa \ 1 X ' t 1 k " 4°1 + P 3 it oye Al A to, view if It 24, 4, c rroy Forlx5 Ave, J p 1 r, NtA olo (D© '44"::: ` aim{ '. ► i't510. 1-effn , eSkS • c1 00 Str0e4 affirm 2 ■ • 5 / 7 g• cQx r«A Skirl • as f300 Ski -S . C wk11 Skin (SS. ratMo\ err umminimmion 2 t 1 I 1 j 1 OCT -10 -06 TUE 10 :4$ AM ATTY. SUSAN J. SHp 4623640o MORTGAGE LOAN -\ INSP TION `ul ,1 r 1L- [ .45 r/ { . } 5 1 t X7 ! sox foga PACE AO 1 gill AUK 3 9 sm6€ ae I 1 G. _ Elm , , ,._ .._. . i r575#1 ter t 4,1 i t } i t } 19' ty'. __ 1 1 t i t 1 PAvE0 s t P�11'E I t t 1 1 } 1 V.9'+/ is is o } r* FORBES AVEME Greanfiei i Savings Bank _ -- _.:_ ...�� — Tch First American Title Ins. Go. 1OWNBL Helen B. Bishop 1 busby Vag list pmt deem assthis plea An ' LOCATION`74 Forbes Avenue tot skids sFlood listed Ares a doss °mho j Northampton, Ntessac2u sett Simms ► p,, I 25 s7-O02 I C .1VI Car HOWE, . 1 Itngineata Et c Mi3db Apr.Li 3 1978 Ps}Dfd>tsiai�utl Land E1 Std & C 1 W7 UNION SMUT, SASIMANEPTON MA, 01 0:77.094$ *be Aloe. ti tiabatarm Isowiedgs. istassarass 1 t7/MACaar> CUSS/7 MA 010 1.7,41/6 Wet this dtititspectianrigs &Am Ss i 73 loSIMMON sr U7st NORTH MILSAMPORD MIL 01863 maistar irspooskeenle 64 lostoiss Ikepremiss ISISkstOttec Ness assasolosesis tWsk tst r tw p . 1° 20` i tY� at orally a Ds" =opts* soled. I *sew Em>LY r -, synth Wok Sete are nosasmmao r sac g r. 8. i1 DATE: but eit ias- st,a otitmotai ; U II 6G j timber 16, 2$ 1 r y iS °� X381: .� .. b :rua� 05 - 349 1 'Mari A13I t i.:. r 3!(g'1 MVO= ONLY"AI DOSS MOT CONSIT7171B A PINSISIcrt ' S[TSvrir. AND smarm Saussa1 lcOlPiAiirffir' OORLAl'c11Y( ' ({ The Commonwealth of .cidassac/zusetts Department of Industrial Accidents ) Office of Investigatiotzs g =.4.1 ¢ 600 Washington Street �� Boston, M4 02111 �y www.fnass.aov /dia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business !Organization /Individaal): .- ' Address: / City /State/Zip: /Phone #: Are you an employer? Check the appropriate box: " 4.e of project (required): i 1. employer with 4. ❑ . I aria general contractor and I 6. so New construction employees (full and/or part-time).* have hired the sub - contractors C " 1 ` 2 ❑ listed on the attached sheet. 7. 0 Remodeling I t� . am a sole prop or partner - ship and have. n. ,-- nployees These sub - contractors have. . 8. 0 Deriaolition i wort n� g for me in an employees and have workers' y capacity. aci ty. t 9. 0 Building addition [No workers' comp. insurance % - comp. ra mcunre- _- required] 5. ❑ . We are a corporation and its 10.0 Electrical repairs or additions 3 ■I- am- a- homeowner- dding-aR -work _ ..... _o v xerciced leek— -- .D-Plumbingrepairs or additions myself. o workers' co right of exemption per MGL �' 12.0 Roof repairs insurance required] t c. 12, §I (4), and we have no . employees. [No workers' 13.0 Other comp. insurance required.] `Any applicant that checks box #1 must also fifl out the section below showing their workers' cot policy information. . t Homeowners who submit this affidavit indicating they are doing of work and them hire outside contractors must submit a new affidavit indicating such. IContractois that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the subcontractor have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site _ __ ... ors ation. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: . • . Attach a copy of the workers' compensation policy declaration page (showing the policy number and ea date). Failure to secure coverage as required under Section - 25A of MGL c. I52 can Iead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $ 250.00 a day against the violator: Be advised that a copy of this statement may be forwarded to the O.ffi'ce of Investigations of the DIA for insurance coverane verification. _ I do hereby certify under the pains .and pencritiPs of_perjury that the information provided _above is true_and correcx i a.. tore: ` . _ IMF- f II a te: _ Phone #: " 1 1.3 " 4- - " S y ' li - Official ztseonly. Do write ti Ydzs di-iii, be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): -- L. Board of /Stealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 7S0CMR 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 .regulatians_Theinspection prccess_rtquires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough buildinginspection (before work is concealedl, insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secu- re.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 ---- P�*M� +s in cc junction to_the building pemutissued,_ 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 /- / ` w understand the above. (Home 1 ner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location !./ f Ave Flor -€1p,, tyn / MA aI , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone.:. -" 9..Regi etii:1'[onte iiiiiibV rigif'•Caiit ct 41„ ,.. 4, ; _ .. , 4 .... Not Applicable ❑ Company Name Registration Number e _. Address — - ,. Expiration Date f - Telephone _ SECTION 10- WORKERS' COMPENSATION INSU CE AFFIDAVIT (M.G.L. c. 152, § 25q6» Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buffing permit. Signed Affidavit Attached Yes..„r.. ❑ No ❑ - _ .._._Thecurrentexemption_for `jtomeown rs" was exte 'd to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an i tdual for hire who does not possess a license, provided that the owner acts as supervisor..CMR 780, Sixth Editi Section 108.3.5.1. Definition of Homeowner: Person who own a parcel of land on which helshe resides or intends to reside, on which there is, or is intended to be, a one , o, o family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who co 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 S upervisor 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 o amp on r .macs, r . . , ,; ... . . - ... al- Laws-Annotated. Homeowner Signature - __ SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House 0 Addition El Replacement Windows Alteration(s) n Roofing n Or Doors D Accessory Bldg. 1 Demolition n New Signs [0] Decks [CJ Siding [O] Other [0) Brief Description of Proposed `� Work: I, . At- - ii, + t - TA eS `�`- /02x a9 Alteration of existing bedroom Yes ••• No Adding new bedroom Yes j No Attached Narrative Renovating unfinished basement Yes / No Plans Attached Roll - Sheet sa l; "` eW,!t'oust`.a d rt.addiiiOn'" dexl:s 'icf Boil iiit ;tbliipt4te_f ief61F6vrin 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 Ta OWNER AtiT tORLZATION TOI3ECOMPLETED WHEN OWNERS AG OR CONTRACT A FOR BUILDING•PERMI I, , 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 i - le - V` ( F, tO it , as Owner /Authorized Agent hereby • eclare that the a ements and inform - on on the foregoing application are true and accurate, to the best of my knowledge and belief. r' Signed under the pains and penalti s of perjury , f I rC 1 r1ip �' , ebt. P PrintNfine /) J t' Signatu •(Owner /Agent Date • p Section 4. ZONING Alt Information 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 t 2- _ _.._ .__ _:_. _ 1- ___ _.. Frontage _- __—. Setbacks Front 1.5rj j� t�� � \ Side L- R r L R rc '_ __i Rear . : . .' Li-i Building Height -- Bldg. Square Footage % !.,-3-7.2-7 t Open Space Footage % __ _ (Lot area minus bldg paved __._.1 ,.--,;_Y `t 5 °' parking) # of Parking Spaces Fill: , 3/2., (volume & Location) -- -- ' ' — _____I A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 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 i ' Page! i and /or Document #' B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 o or a itions of signs intendedor t ie property ? YES ( NO .0 IF YES, describe size, type and toca inn. E. VII 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. C tf y of Northampton Status PerTri a x �v3; Buildin Departmentrrit'� 212 ain Street Ro m 100 ^�i etl3it� "w No pion, MA 01060 A� .� �Y - phone` 13- 587 -1240 Fax 413 -587 -1272 g. ■ A 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 1 4 1 6 f bc'% Avg Map Lot Unit N 6�`l kor M A Zorie Overlay District OIo(0b -EtnrSt District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i _a bus - Att t ___, d_b o}, MA Name (Print) Current Mailing Adslress' y -ri(_/ Telephone Signature 2. A'Dtherized.AUent: ,. Name (Print) Current Mailing Address: Signature Telephone SECTION =3-- ESTIMATED Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building C7 3 L5 3 (a) Building Permit Fee 2. Electrical 5 45 60 ( b ) Est Total-Cost of Construction from (:6) - 3. Plumbing j _.___ Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection Kro , u0 6, Total = (1+7 +3 + +5) J{) 000 Cheek Number /t9 This.Section Official Use Only Date Building Permit Number. Issued: Signature: Bullding :Commissionerflnspector...ofBuildings Date File # BP- 2010 -0259 APPLICANT /CONTACT PERSON LEONE LOUIS & VIRGINIA ADDRESS/PHONE 74 FORBES AVE NORTHAMPTON (413) 727 -8541 0 PROPERTY LOCA zi4 FORGES AVE IALLWL 7 t t 1 ONE 11.1% 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: CONSTRUCT 12 X 25 DET GARAGE 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 • ' ION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P r. SENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ C.• 3 Intermediate Project: Site Plan AND /OR L Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § 40fA7 , !/VO Finding Special Permit Variance* i4 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 Dat- 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. l i . .. > . ; / . . . / . , . I t , , ' .., .„ I ,. 1,.., ' ;1", % 1,1, . . . . ' -- -d r , 6.- -,,, - ,.."-kC. , 7'.' t ) ,, 4 ..„" ' , 7 . 5,4 . I. ■ 3,,,1 / . . . , 1 . ' 1 , .............., i I . , . , 1 ' . , . 4 4. I ' , Ne'' /1////1 • , i - 4. ; i 1 j J . . , . ; . r 1 t .....‘ .,... .., ; 1 . i . i .... ..i . ,.....1 , i I ..„ 1 ...i _.,; ...i, i .., : 0...,.. ,... .., ,,,... .., .. ,..., . , i .. i„. 4... -. . , . . ,....--, ‹.... e .. J --..- . x Z 1 i 1 : 1 ' , . . , . " = i , . . , . . . 1 • ,,,, . i r \ v ,.: r --„, L------ 'WO , '3: 1 ; i ,. „„ , , . , 1 • ,- \ \ . 0 ' 'i , . , ...,, • \ , '', ' ‘ — 0 A oi - 1 \ 00 • - , I_ ..,..__.i ; .1ki . r J l ' °) .. ' ' ' \ ' t • 1 \ /ft' -......, --..„,... 1 \ . ' •, I i ! , ( - -....,,, \ I_ , , \ \ , i • , i . . . . I 7. . „. . 4 .... 0 V ... 0 \ t 7 _ . .. 1 i (7 . / _ _ • (' ,- ) -,., ,, - , t 1 .,, . ,., i I :— • I • _.. . .. , ,,,,, ) .,' ., II, .:'•..i.: ;it Sap 25 09 09.07a Lisa Gibbs R E 4135840538 p.1 w.s2=6.4e0 p.01 'MORTGAGE LOAN INSPECTION , . L It'et . 1 / LOVA REFSETICE , GANGE NW 090 PAW lig PUN soar 39 PAGE 21 Mr M.S4C \ __, k PLAN 30tar ZS OPie SO . ' • .-• or* ,.., t &,.Y•1 , :”.°,;„,?: 6 • 7 C. w, ‘ • E ' • 1 Z , :Th - I -. E arJAY FVF 1. , 4 - E .,..,.„ . t ,,,...: • , ,t , . .., , NM t , i• ..' 1 .. . 1 ,_' t . • 1 PA7 1 . ■. , % , 4 1 % I N 1 1 ... • - 7. Se+/- IF 7n - - r + , 1 1. , FORBES AVENUE Ok Greenfi4d Savings Sank - 1 0 . —....--..-----------......—.. ..„. qrst Aoaricen Title Ins. Co. vWNER: Ualen B. Bishop AND: ________, : 1 har.by qprt dud OW ptc0444 blualna en ties pls nvocA e moo ON 74 Forbes Averitle not td *Alin • Mod germ Asonars &Amon the liOr thamptOM, Ms s achuse t WI Feted EmOgnocy Minsoltnent Armors Mond . Ittsunnon pew Men, c No. 250J.67-002A . HOU/IRMO & HOWE, INC. mo D 121..pi.978 Professional Lae4 Surveyors & ace Engineers $7 'MON STREET. EASTHAMPTON MA el 0:17-0,43 I limo opor, to lobo& ofmYlmmrialgs, iniMrostiog a/ EAMON POMO SOAD. oRHSTEEP)MLO SSA Oio12-017‘ tnalselin4 OW this tope:4m On abaft du 73 P4014 syssirr, NORTE 01.131.24101RD MA 01363 immanent or vvattionts 0 itexted on Me peeniste $nsculn amens impentemeetr ate telizolywhitia int . SCALE: lioes„ and Sot Mae No se eactenottotnedi upon tbe 1" - 20' ... , poWitest domoribed oy tin imeavemos MilkVimattas . (,,,- - The et . (C,y day &Uniting pianism, essept as soled ll Ream .itY EIARY mod tbattlato ure no costsnads nirsoottlstrodisS tin k B E. .. DA WA Mows Mato% Ceara as soled. 11 HOIABUL0 ;,1 i 0 4 034Vg ...,/:;fr Noverober 16, 2X15 1 7 "-- IP ..„b.c.„,, ,,. J013 NUMBER: • ei 05-34 — - _ —..1,57:;= • . Tios PLAN FS • : , 1 ■SNEFICAZON PT-TIMMS ONLY AND mommorcoNsTrruna Aruoefacry• scowler. , AND ISIvart0 DS IMOD roscaNssuncriuti PLANNING OR LAYOUT. . - . 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 Theinspection 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 --------- - - - - -- permits- in- conjunction.to the- building._permirissued, 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, `4 - understand the above. (Honii owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location 7- -FQ_dizs ,4 J e, _No t=k\IovYY1 � 4pn /U1 A 01060 . M The Commonwealth of Massachusetts Department of Industrial Accidents =v1.- Office of Investigations • l0 600 Washington Street � 7 ••"' Boston, l"t1A 02111 www.mass.gov /dia - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): Address: City /State /Zip: Phone.#: Are you an employer? Check the appropriate box: Type of project (required): ! 1.0 I am a employer with 4. 0 I am a general contractor and I 6. XNew construction employees (full and/or part- time).* have hired the sub- contractors listed on the attached sheet 7. 0 2.0 I am a sole proprietor or partner- Remodeling These sub - contractors have. - ship and have no Ploy ees 8. 0 Derio,on for me in an capacity. employees and have workers' working Y P ty. 9. 0Ikulcli ° addition [No workers' comp. insurance camp._msurance_ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 1 -am -a- homeowner -d i gel -work- cers _ve er_c d_their -- 11:0- P--Iumhing 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 workers' 13.0 Other comp. insurance required.} Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such_ ZContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. Iam 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: Job Site Address: City /State /Zip:" Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1 and/or one :year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fe of up to $250.00 a day against the violator. }le advised that a copy of this statement may forwarded to the Office of Investigations of the DL& for insurance coverage verification Ido_herebj certify under the pains and penalties of perjury that the information provided _ above_is_trueandcorrect_ ___ • Sisnatttre: _ - Date, • • Phone #: �/ 7-2_7 - 5 4 f' . Official use only. Do not write in this be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Insmector _ _ 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered; Home ImprovenientCohtractor 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 ❑ T_he_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. Alco be advie €d that unth refprenretn Chapter 15? (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) youhire to work foryotranderthis Nei uiit. - -_ -__ The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Vr tnadn a te — • � . / • w e s= Getier-al -Laws Annotated. Homeowner Signature (j ,tom -C-G-- �"Y • a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition Q Replacement Windows Alteration(s) Roofing E �t Or Doors El Accessory Bldg.j + Demolition Q New Signs [D] Decks [[] Siding [D] Other [D] Brief Description of Proposed 1 ` 12x 2-(o Work: 5 I le, ' L.rn.•( O�O�XO�i✓' -1-oo n 5 1�?� L , Alteration of existing bedroom J Yes ?C No Adding new bedroom Yes >i No / Attached Narrative Renovating unfinished basement Yes x No Plans Attached Roll - Sheet ' sa. If New house and or addit on 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, i f i h i n. L-e me... , as Owner of the subject property 11 hereby authorize ri� - 111; L - v to act on my behalf, in all matters relative to work authorized by this building permit application. Signature o wner Date I, V ifoq 1 ntoL_ L-eone , as Owner /Authorized Agent hereby-kleclare 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. Vi q;nio. Lenne -- Print Name J Signatur= of Owner /Agent Date Section 4. ZONING All Information 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 Fronta Setbacks Front 1.5 751 Side L. R..._ ._. L: '!� ..._ � R. Rear . ' ... Building Height Bldg. Square Footage Open Space Footage % "' _ (Lot area minus bldg & paved i parking) # of Parking Spaces 2 - •. Fill: (volume &Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW ►fie 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 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO i►�� IF YES, describe size, type and location: D. - ` - Are there any proposed chi nges to or ad rifii ns intenTedT r tl';e property ? YES 0 NO ogi 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 ��� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �� `�� � Departnaent�s�nly City of Northampton Statris f Peri it Building Department CurbG Dnveway o 212 Main Street Sewe e tic tlab(It ' O CR Room 100 1t1/ o iM taa la l�i� Norttfampton, MA 01060 phone413- 587 -1240 Fax 413 -587 -12.72 4 �efS�t~Gka a� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION ' 1 n J This section to be completed by office 1.1 Property Address: -Fb{. be �-t J Map Lot Unit 1\)/5 -r+tr\PLAY) 'ApfklOY\ , " /�/� ` Zone Overlay District 01069 EIm St. CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1L_ ur_>r� i C-• - � -F�f1 S _11� , mlf+ho►lm nn A Name (Print) p, c Current Mailing Address: Signatu� Telephone ! / - 2 t� q r , 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 q3 n 5 ( a) Building' Permit Fee 2. Electrical (b) Estimated Total Cost of 5 . 00 Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection I CX) , b 6. Total (1 + 2 + 3 + 4 + 5) C.) t 000 Check Number , `� / i • This Sectinin Fnr fffir.ial Use only Date Building Permit Number: Issued: Signature: Building Commissionerilnspector of Buildings; Date File # BP- 2010 -0468 APPLICANT /CONTACT PERSON LEONE LOUIS & VIRGINIA ADDRESS /PHONE 74 FORBES AVE NORTHAMPTON (413) 727 -8541 () PROPERTY LOCATION 74 FORBES AVE MAP 31A PARCEL 137 001 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 r� Fee Paid 49 A6 i g o Tvpeof Construction: CONSTRUCT 12 X 26 DET GARAGE 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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 . , ,C). 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. 74 FORBES AVE BP- 2010 -0468 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 137 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 -0468 Project # JS- 2010 - 000646 Est. Cost: 510000.00• Fee: $62.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 7448.76 Owner: LEONE LOUIS & VIRG`N1A Zoning: URB(100)i Applicant: LEONE LOUIS & VIRGINIA AT: 74 FORBES AVE Applicant Address: Phone: Insurance: 74 FORBES AVE (413) 727 -8541 0 NORTHAMPTONMA01060 ISSUED ON:11/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 12 X 26 DET GARAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings0 Rough: Rough: r . A douse # Foundation: !i /. ( 0 / �1 Driveway Final: � �,� 6 9 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 VIOLATIpN OF ANY OF ITS RULES AND REGULATION Certificate of Occupancy 14Pr Signature: FeeType: Date Paid: Amount: Building 11/9/2009 0:00:00 $62.40 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo