23B-069 (7) 4 0
•
000Z I NIT
„,--1. .
7 4
\ .g.....,
- '.. , , t ..% ' ' ''' , - \
i - / i
,,f, --.
A ic,1/4,...,
_74.. ,...„ k. '
,/ y
I ,. -// / /r // .S
isi 1 -- I • t ) ''''' ° . 0 (-. "E ---
\ IME 4>.;4.
11114.°111011" ..5•• ....k5 >157>""`• .
1 011HimillailliftAlig t •
1 1■ 114 0 .&
f .., obi ,P1,:. vi
so \% ett, .,q ..4, ...i
-e
re V_ . ...is , ,:,:igl o ye - .//,... 0
0
t-.:. . -..
f l
l► � ) 711.0 ( • °.44 ,,
� �� VIII) ''''' 'L. .4274 ID , ; i �
I
vp, ,,,,,, (4 ," , (--i - " 1
l�
fiA , 4 I/
fa 111-::\ 4, A
k ( 2.4". It
r/'�' //� ii ,-. / / /•lam /�(
Joh lik # „ .....
- , ,...___.....------ Ur 9 it. 4: - VIM ' `__-_) \
Oil 7 . 1 \ i - - - .t.
4 -e4,
0 i;
„ i
� ! ,, ,,R,tol*e i'iii 1
i ---,_ one ' vg /
•
1 ce ii.i' .--0?0(._,. -6'
fa ,. •,,, it '6 ,
irrro.: iroff,1 ,..
k rn f",
N-,
I 4.-
..-- 1
---------" ---j- ASV, ■44.,
/ 9)
a r ,181\_1 I f
cam'' r. - \ 11 0 ?---- � 4 ye.
(Tic/AT -IA 1 K 1-17 r� ,�'
L-V-1---1°A1-- . a ..,,,,,,:„..,„(....;,-, ,
�
' •
Nnr •
I
�
/ .
. ,
• . Ty ;:. 1 -, :-, i t,t., y., .' '
r .
s..)
I -
:4 snort RAN.
d )
Q.)
‘.-
4C:, "zr
o rir,.... ....
"'"\ -•;*,..,,,, fr k es
4_1
-.............r..... ce.
of,4
pr
------- 0
i F1
%
• F.
er:
rA
kr■
Fidtr..?? '%,.... --ri,... 46
/ p • ., '/>.. W. . 4 ''',A
1.. ---'
;;;" - 502;je' ..,47 ,, -.P-
.-•,.-.4 ..„ ....,, ......., ...-...„ ....-_,,,_ ._,...,-,.
,.; I :: / 4 1' 4 eo ---,
I 1 S',.-----_---------> . s
Al
1 e. s o 1
ir,::::- •./ 21 Tao ,0
,:,.., ii ,.... ‘... / 'V 1 IIIC.9
N s" l'
01 a c
, or,
•
di
> •;_„::
I X-
t % 1 111Ir ;Pall
cf .4/
t A
........... i ..9, _ • .. ir ' - • b .. ire ... 5 .
"..----- ....-- ..d.e........ 7/...k...779,
1" ......
,,,,..
_
s,\:)
• -1
Vt:t
r I -
-------- ; — 1 .
yr. w ■ „ :'...--- I ;2
1- 01.1? -17°
_I -- I" P" I 55..1%.4 910:
Colt ..e.; set . e
I ..1.•••"i.1-.._-__. r.di
„:■•
,,...- rarstlas * 4 "% 1'
01;e4 ) 6
;"i' -, . .h.” 4 .....--■■ • ';:.1
1/10; -..,..
,,,,,AP mow! 2 ,\,
, .
or - ir
e 4. 41".1".../..FAIV■117.1—.7./P.,"/Ze""4"4‘,./ j f.- ;; ; :a °;: ' Lill
...
,,e: a (IP !1
I 44,
,..,
1, ii ; prisma
%. " '
f
el
.s„.... _ ... .r.............---..,........... fi,
4
r ... ■ .
ti\ ' l'
,....
r .. In
.1
r•-, lb • ■41■`■ C:)
‘. io;
11 /1Mil,
F•
ei 0 1 irlot. 4 ,•71111111111111 ..,
0.
0 0,
r1
,
kik
,..,
I I,/,
--- e
l ,....,, ,.
, . .
Fi 4 o',!4 )
1 4
L'
v
N ot cbv��a,� cnau •�,
C�,?(Zx ,, hZ) dip r F X
..,off gtts 1,401{.s11(a
e
S 1.??
cwz 61
4..it, 2, 9 s,,lnw ot,IXti
, fJCdd2 ,b —,g
P f'O'14"S. VII }41a,)a7 • a SXS 1
,c S Y+2aq u!2w
XI. cx9--,,,,
1111110111/4014111111111.1111111.11. 11111111111111111111111111111011111t
11111111 14- # 51 la
c
•
, =, + / I
-}°° - 1 I
.1►,Q
.g
11 PINI � UMW
/oo1d '4g 1
rrtrn AI \ 1 b , I
,--- -- 19 ---->
rKM
g.9 . , ,h
+ppn{ -S 1-,X2
I I �/� ..1 00 4-9,1
•w5 0.4 10 V 11Al 1 ‘
,
-; S
, o ,1 91 ,
yv1Pp(AS h )<
h%2 < repu,vo c .,opvl•n
r -
diary at( Z1XZ
Oaaa 6))1 u ) LT 11 C -
,Jo ,,t.xa
o+ -'v?,
• 7• o ,q f 'k---- ,9 -->' 4.7 • 7.0 .9 / ,8
hxz hXe
-Mp ?y - 21% - z
,1 1 1 1 ;
.40OI3 -I I
WQO.luos JT N+
- ,'
(---•— ,9" —‘ .8,9
• , (2 .11 �u S ,a
1 r - — 1 t .d. e .0.2 y Z 1 )CZ
000ZC{NIT 1 :7 I 1
'. v
A i
•
,-.0%..A xrpi. �
0
_ti (it t1) of Northampton 1
R r � � � • E _ _=
r ok 9 . ' E �tcssachncctfa _ • 't=;
�. :.' ��� 3 L
- DEPARTMENT OP BUILDD G INSPECTIONS
�
212 Main Street • Municipal Building
Norlhampton, Mass. 01060 r>
WORKER'S COMPENSATION FINIS 'Cl✓ AI'FIM.VIT
I, C,J A -1 1 XS ie - (h perm tcc)
Y u/I/1 'j
with a pri icip pla cc of businessIresi encc at:
I LU � ,/ f
(:s��ikd /city /staicinp)
do hereby certify, under the pains and penalties of perjury, that
c kI zrn an employer providing the following worker's compensation covet for my
employees worldng on this job:
25 (04 Lgt li (OW 1) q 1 i ab
(Insui Coon =n\) (Policy Nu_ r) (T ; -pinion ate)
( ) I am a sole proprietor, general contractor or homeowner (cu oe one) and have hired
the contractors listed below who have the following workers coFa Densa policies:
(Nnmc of Co:ltracwr) (Insurance Company/Policy Suing) (:_ pirat:on Date)
•
(Name of Conn cior) (Insurance Company /Policy Ntuncer) (x- pimiion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiraoo Date)
(Name of Connacior) (Io_surano Comoany/PoLicy Number) (E.piration Daft) ,
(.aach adlit; cK J txC if occcsirl co mc!u& uaforra•a on per /ains to all Doura-ors)
( ) I am a sole proprietor and have no one worldng for me.
( ) I am a home owner pefforrning all the work myself.
NOTE: plc be aware t},c u'L^_]c hoascauvcr• ubo ccaplay pc•oas to do c^. r-+ ca - - x) a- it,uu work 03 . d..rni of
noe roar the n t`.,r- o-_ L tti in \' aic tfx twrmot•vtr mvdc or oa the ground, apptut.ca nii thet±o r_rc ax €,,,,_. .11y cla :d-ni to be
c mployc ur c the ..•ic{z c rn iico Acl (GL152. 1(5)). nppliratioo by • hocnooavcr far c l;c _ a perms rnzy � t c
Icgal -tame of an .cgloyo- undo- dro Workcet Cocapoa tioa Ad
(")
I undcr.taod thud a Dopy of this rtitimm m. ty
c bo for u-d.ed to tba pogo- rtm•o¢ of Ind•zn Ac
d Ad41 . OfGoo of 1n t+r for tt•
cov crtgc vczij'Gtioo and that L•iltzc to toctrc covccnsc under socfioo 25A of hint 152 can Irid to the i position of cnminsl pcndiics
ooas.iring of • Ctnc of up to s 1,300.00 end/ex aaluisooaac4 � a m.f
of to one pose eril puo is thz form of e Stop Work Ord an
er d a
f of 5 1 00.00 . by gains me
Fa r- tn>�i1 u,c only -- - - - -
Permit Number
•, v 6 �1 a C.0 i gyp;; lot .
Siggatt - of Li 'cnnittcc thte _ - _
,
SECTION 8 cONS'tRUCTION SERVICES
e llik '.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ��a -44-d A. 6 ,-/ks.c.e e 6 Q 6 77
License Number
67:r&;17 . L/ � XcL_ o' , X1!4. 2/ 3� 6 /
Addre Ex ate
Signature Telephone
i 5 N I�;), ;ci � , ; �;''',, «At - . 1: , Not Applicable ❑
-4/ 40g3
Company Name ' I Registration Number
Ai t t i Address Expirat Date voz.
V If . bitary 61101 ail bf -- Telephone `ii ' JUcf %
'
SEC' CN 1O WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MA .L. c. 152 § 25C(6» 1
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 Ri No ❑
1
' 0. i l
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
eak
New House ❑ Addition ❑ Replacement Windows Alterations)/k Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] 0 her [ ]
Brief Description of Proposed Work: Wt'i_�(,(
Alteration of existing bedroom ✓ Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
a . ` ' Mlit® ® 1 ,. & ..51 A . " , _ 1 ;: ' ..,. 0 ' ! a t °, -,. ` i a .' i `::
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms .3
c. Is there a garage attached? rn
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 2+
f. Method of heating? 4v/ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. /� Mascheck Energy Compliance form attached?
. Type of construction Gt)6DC7 e. ',4 2, % -
i. Is construction within 100 ft. of wetlands? Yes le Is construction within 100 yr. floodplain Yes _ No
j. Depth of basement or cellar floor below finished grade 8
k. Will building conform to the Building and Zoning regulations? V Yes No o..
I. Septic Tank City Sewer / Private well City water Supply te
SECTION 7a OWNER AUTHORIZATION = TO BECOMFI_ETED WHEN
t GWNER AGENT OJ°CONTRAOTOR APPLIES °FOR 'BUILDING PERMIT
I, .... ( . 1 -- 7 Dkli as Owner of the subject property
hereby authorize God )eski ' , My 77344t ywa'I/L —. to act on
my behalf, in all matters relative to work authorized by this blinding permit application.
Signature of Owner Date i, ] 1:0
VV
I, , 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.
%geed under the pains and penalties of perjury.
44Z' W' i l4'
- rint Name / - ,
A IA
t/L./ 41 6 pD
Signature of Owner /Agent Date
•
Section 4.
rkk ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding e been issued for /on the site?
NO DON'T KNOW �/ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registr of Deeds?
NO DON'T KNOW V YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ✓ DON'T KNOW
YES
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 NO
IF YES, describe size, type and location:
r ok D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location: