38A-037 SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
e i eyed, or e:m."rovemen.¢ ontra' o:1 W ,. , Mt; .,.. i M .t.. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
u
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 ❑
sin' rite -.--empboAi
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 a d Local"Toni g Irs and State of Massachusetts General Laws Annotated.
rt
Homeowner Signature
•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
1
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding[D] Other[D]
^
Brief Description of Proposed �` �� /U�
Work: :��21lJ(e+e_ (D(G� t �`�IC�C_�. l / Ll/
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t ,e `ou - o•nor*addition eta exis ujci hoi�sWi �cohii e`e.hea�oU viAq:
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
OWNERS AGENT OR CONTRACTOR APPLIES I OR BUILDING PERMIT µ„
, 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
, 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.
Signed under the pains and penalties of perjury.
vt_
S-�_ 13
gnature of er ; nt Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b
Existing Proposed Requied by'Lpat'.,
This cdlumn to • ,, in by` I!1
Building Department
i
Lot Size i I
Frontage = ' H i
Setbacks Front i I 1 1 I i
Side L:'- 1 R: 1 L:1 I R:' 1 i______I
Rear
1
Building Height = I
Bldg.Square Footage
Open Space Footage 1-1 % --
(Lot area minus bldg&paved
•
parking)
#of Parking Spaces
Fill: I --- - . ___ .....___..._._._
(volume&Location) I 1
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 and/or Document# ,
B. Does the site contain a brook, body of water or wetlands? NO ;.,,,,e DONT KNOW 0 YES Q
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
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
IF YES, describe size, type and location: 1 1
E
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 Q NO et
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
REtRECEIVED h 1U , , ,5,7.
g,. ��
Cit of Northampton S#a u ¢ 4' �a O t
Bu ding Department
MAY • 9 ,v,: e•• m °tz '. @ >
� 20I3 2 • ewe a t F
. a
Room 100 � �11 ����t
rth. mpton, MA 01060 ' � �`� :
• P T. BUILDING INSPL-CTi a�» ® a ` ,
RTHAMPT•� IuIA 1" + , r 1 : k h r -. ��
N0 - - ;7-1240 Fax 413-587-1272 m � � �4� i':,..
. ®.. .'.:.$�. a : =s , '*41 �� is F :
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
°tea
SECTION f4 IT..E INFORMATION
, ": This sct on to be omple ted byoff ce 3 A 1.1 Properly Address: pg
, t-4 . �1 zgl
-
G o c 1-s Pt-71_ r
)\10,4144Y41'nflIZIA ", 4 s i� &am � i ll 1:': S te"' , * � il i A �
One # r + 011p � DIStrICts' ��
acts.1, y�,u" it 'S, 1-.-- y s �1 t t,, ,„..,:g.„ xp'L4"awi�" a` '
tit SL i Ct *S i lrt R £PIS{l G s'4 `S i y^f'Sf' 4 .
SECTION 2 .PROPERTY OWN ERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
Cif �1(.Vt.)LL I31 keu ►M Olga?
Name(Print) jJ Current M fling Add Telephone
Signature
2.2 Authorized Au nt:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS'a "
Item Estimated Cost(Dollars)to be Official Use:Only
completed by permit applicant
1. Building
E.� O (a)Budding Permit Fee
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
This Section For Official'Use Only
Budding Permit Number: IIsssued:
Signature ._.
r
Building Commissionerinspector of Buildings Date
60 CHAPEL ST BP-2013-1080
GIS#: COMMONWEALTH OF SACHUSETTS
Map:Block: 38A-037 CITY OF NORTI 'TON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERi ,TRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY (MGL c.142A)
Category: ROOF BUILDIN ' HERMIT
Permit# BP-2013-1080
Project# JS-2013-001781
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRAN' '0:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 37548.72 Owner: MERRILL STACIA A
Zoning:URB(100)/ Applicant: MERRILL STACIA A
AT: 60 CHAPEL ST
Applicant Address: Phone: trance:
60 CHAPEL ST
NORTHAMPTONMA01060 ISSUED ON:5/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI P & SHINGLE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Buie ,cctor
Underground: Service: Meter:
Foo!'
Rough: Rough: House# 1' •
Driveway Final:
Final: Final:
Rn+ n;
Gas: Fire Department Fir.imney:
Rough: Oil: Ins>
Final: Smoke:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAM P 'N VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/9/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1 '
Louis Hasbrouck—Building Commissioner