41-043 (2) SECTION 8-CONSTRUCTION SERVICES
i
i
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Ga'eia.4. j 62(.. %/5-1
/59
License Number
P. r 62 127.4 a/o? 7-/3 - zalc1
Address ' Expiration Date
�� 9/3-695 - 7a59
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
1,444.%."/Re/ /50890
Com.an ame Registration Number
a 4Z / 2,1.4 a/o% 6-3 -2v//
Address Expiration Date
_ 7.'d-zi
Telephone q13-695-7059
C
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 build ing permit.
Signed Affidavit Attached Yes �3'd No ❑
. - Home Owner Exemption
The current exem. •.n for"homeowners"was extended to include Owner-occupied Dwellings of o. 1) or two(2)families
and to allow such homeo o engage an individual for hire who does not possess a license, • i vided that the owner acts
as supervisor.CMR 780, Sixth •lion Section 108.3.5.1.
Definition of Homeowner: Person(s)w : own a parcel of land on which he/she res.. s or intends to reside,on which there
is,or is intended to be,a one or two family dwe ',.,attached or detached struct -s accessory to such use and/or farm
structures.A person who constructs more than one , ' e in a two-year • - iod shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on . .nn a-- stable to the Building Official,that he/she shall be
responsible for all such work performed under the building • ••'t.
As acting Construction Supervisor your presence on the •e• site will be _suired from time to time,during and upon
completion of the work for which this permit is issues
Also be advised that with reference to Chapter 1 (Workers' Compensation) and -..ter 153 (Liability of Employers to
Employees for injuries not resulting in Dea . of the Massachusetts General Laws Annot. •.,you may be liable for person(s)
you hire to perform work for you under is permit.
The undersigned"homeowner"ce•. ies and assumes responsibility for compliance with the State B • sing Code,City of
Northampton Ordinances, Sta • and Local Zoning Laws and State of Massachusetts General Laws Annot. ...
Homeowner Signat e
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing FV(
Or Doors D
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [0 Siding[O] Other[0]
Brief Descpn o Propos d
•Work: • . .4Jur ,ems
Alteration of existing bedroom Yes 1/ No Adding new bedroom Yes 1/ No /
Attached Narrative Renovating unfinished basement Yes 1/ No
Plans Attached Roll -Sheet
6a.If New house and or addition 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 .X l V//cA -e,/ h-e'--- ,as Owner of the subject
property &1240/1411+ /
hereby authorize Kam!
to act on m behalf, in all matters relative to vk authorized by this building permit application.
..A� VVV 3/ 2413
Signature of Owner Da
I ?f /etc/ ,as Owner/Authorized
Agent hereby declare that th 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.
CDwARP RJcJc6'7'
Print Name
L 3 20i3
Signature of 0 er/Agent Dat:Aar
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
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 Sp ial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was t permit recorded at the Registry of Deeds?
NO 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 e( 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 Q , Date Issued:
C. Do any signs exist on the property? YES Q NO el
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO el
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exc ation,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.
Department use only
f _ ity of Northampton Status of Permit:
':uil•ing Department Curb Cut/Driveway Permit
2013 21 ' Main Street Sewer/Septic Availability
oom 100 Water/Well Availability
nE Noti� tom'�NNSPeG• : ha pton, MA 01060 Two Sets of Structural Plans
3-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION 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
q� 6om�te� Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: 4146 Z
W3 -5 - lyl7
�`� Telephone
Signature
2.2 Authorized Agent:
7 'L '-4eD /2/G/6 6 Po. 841-x 42 /;72 4/c96
Name(Print) Current Mailing Address:
4//3- 695 • 7os9
Signature Telephone
SECTIO -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building s.600. oa (a)Building 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) S Loo 00 Check Number 02610
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
41 NORTH LOUDVILLE RD BP-2014-0109
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:41 -043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2014-0109
Project# JS-2014-000214
Est. Cost: $5600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq ft.): 195584.40 Owner: SHEA MICHAEL R&DENISE A
Zoning: Applicant: EDWARD RICKEY
AT: 41 NORTH LOUDVILLE RD
Applicant Address: Phone: Insurance:
P O BOX 62 (413) 695-7059 WC
WILLIAMSBURGMA01096 ISSUED ON:8/1/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 8/1/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner