17A-285 (3) SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
License Number Expiration Date
Name of CSI, Holder
List CSL Type (see below)
No. and Street Type Description
U Unrestricted (Buildings up to 35,000 cu. ft.)
R Restricted 1 &2 Family Dwelling
City /Town, State, ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvem Contractor (HIC)
Rt'vtr,r O 1 J m Sv° Y1i't t?.I' Registration Number Expiration Date
HIC Company Name or IjRegistrant Name e
No and Street Email address
rry 'n - , L�..�t N�,`k�r '�w I .3r� - 1)to1
City/ n, State, ZIP Telephone
SECTION 6: 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 ❑
SECTION 7a: 3 WNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S ' ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the su.; ct property, hereby authorize
to act on my beh. in all matters relative to work authorized by this building permit application.
Print 0 er's Name (Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
��lZ>C�y=r2 t
Print Owner's or Authorized Agent's Nance (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 1 42A. Other important information on the HIC Program can be found at
www.mass.gov /oca Information on the Construction Supervisor License can be found at www.mass.gov /dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) _ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts State Buildin Code, 780 CMR MUNICIPALITY
> USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One or Two - Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 11 _ 1 Z
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
tp(. ka(c€. S i 1 R a R 5 C X(. 'C
1.1a Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: j F.& 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public cr Private ❑ Check if yes❑ Municipal Er On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record:
DEV IR R €r� w�� 1w1) N-093
Name (Print) City; State, ZIP
rYl iNt t — St S : : ' * Cla gt, , ue-ck gyai�0 .c,.
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other cit Specify: he: p IC . uJi ✓1c ter
Brief Description of Proposed Work
Rt.:. ∎` t✓u; V X —'- S I I(Ve , �. � f�u7 Wi ne t` u 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fes: $
Check No.0 VVCheck Amo -1 '0 0 Cash Amount:
6. Total Project Cost: $0OCs .ac'� ❑ Paid in Full ❑ Outstanding Balance Due:
66 LAKE ST BP- 2013 -0615
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 285 CITY OF NORTHAMPTON
Lot: -066 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0615
Project # JS- 2013- 000996
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: GODFREY CLARE
Zoning: URB Applicant: GODFREY CLARE
AT: 66 LAKE ST
Applicant Address: Phone: Insurance:
24 MINOT ST (508) 384 -1766 ()
WRENTHAMMA02093 ISSUED ON:12/3/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT WINDOWS
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 12/3/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner