37-022 (2) / D > Z 0
fil 0 o K
0 9 m H
M O O
R - -I o m O
07 2
< rn
0
C......,
m I LJ m y
\,,,i Z
.
D
0
m
vii O 1
V o
_ trio 0
Rj m 3) o ..o�•„)
CD
o v z
I VI m
°°� K 2
c 0 r Aid
CO ON XI
cn
o ( 1r,
Co m N V O,h cWc
o m i N G
-� 1
Co
Fp 73
o. 0
v n a Rt
m 33 o m
5 n 0
N r X m
Q
W >
"4) '-- N-1 :ter o
1
\Se's (
1.2 ftM 010144-z/ LAMER t e (kr) �GJ F4/40
1rip,,Ge 6/a6,
(9/.3) Siq —. 6F 76
I
■
i
G\v.
V
I
A '
.),
1---
4.:5---
c.„
•
'-'
co
I .
,\\
=2 nE
\,.
0,_, ,...3L ; •
ii:::: •
-,.
..,
—cA
71,
C-1-7
—
,
1 . ...
___,
t..
--. N
...-vo• z
kx
--/--- v A
C
G
F ,ac,
V t cO
! E E
CE a,
D tr1 0.o C.-
�. f v� � ���y � r � tv
o i., ✓ < I
c � a I ,'
5 \.)
3 , I I ,"'----
, r--
t ,.....__ -
_ --- \j< (
n ( i,.-,
3 \ c 1 -c- c1
__- , .' A- ‘C-- .>4-
' -
r v
�-
0) 4 ---,
i.
,r'
'`. ..:::-:). %,z, ,
4.
�_1__ ,r,
. . .--- , 15.
ti
opi
of
'� t 4 S c Y
s
pS Cl ,_
l I
1it M
O�1ttA14 P�O
F� _ ,�a (riff of Northampton 1 _
R s� ^v7, �}6 �ZassRchnsrtta — • -�
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMTENSATION LNSURANCE AFFIDAVIT
h
(li ccnscc/perrni ttcc)
with a principal place of business/residence at:
I) �^ 0102
(phoneio vi?-5- 5'"3F r/G
(strr-.t/ci ty/staicizi p)
do hereby certify, under the pains and penalties of perjury, .hat
( ) I am an employer providing the following worker's colnncns Lion coverage for my
employees worng on this job.
(tnstisan Company) (Polio: Number) (r zpin ion Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's coonensation policies:
(Name of Contractor) (Insurance ComoanyiPoiic; Number) (Fxpiranon Date)
(Name of Contractor) (tastra.nce CompanyfPoiicv Number) (Ex-piration Date)
—
(Name of Contractor) (Insuranc; C.ompany/Poticy Number) (Expirtion Date)
(Name of Contractor) (Itlsnrancc Company/Policy Numlx_r) (L-x-piration Date)
((taath additioc,J vccr ifnocazar;t.o include infun..ioo pertninin€to all cow -ocor,)
() I am a sole proprietor and have no one worh.ng for me.
(X I am a home owner performing all the work myself.
NOTE:plc-w be nwa c[hz:winlc homoow-ncrs wbo employ pczom to do rY cazm-.:cioa c rcpau work on.d.ocnins or
mt morn tbao. thrnc no in winch the bomoowncr roidet oc oa the grouo<h appurtenant the–do Lr Doe gcncridly oomidord to he
empleyrrs uodc the uui;u's cccapeimiation Act(GLI52,ss 1(5)),>•pptuation by o homeowner Ion e be ne or permit troy evidence the
lcgol etnnrc of an o.iiployor under duo Wo<icol,Coar po ra ion Act
IIR, I uo -ot&ad t e o copy of this rtotcon o1 auy bo focw..rded to tbo Dep-ortmcca of lchirr;el Amdmt'moo of I,rur 000 for dm
covcngc vrnfictioo and that Liltnc to acctuc coverage under soctioa 25 of 1,MOL 152 can Icad to the impmdion of criminal penalties
coosistiug of a floc of up to S1,100.00 and/or isspri3. ant of up to one yrsr cud civil pmxhio io die form of a Stop Work order acid a
fun of S100.00 a day ogainA tux
For r i t N uri1 cr Dail y
Pcrmtl Ntrti]tX:r —
.S/o Sha
1 tap;i Lot rt
Signature of Liccn 'cnnittce D31=e _-
ilsiggcTION 8-CONSTRUCTION SERVICES
.,.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ttfpirtill fPti€ (E 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 ❑
C:i141 -'144,VVRIett, mama
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 ' /Z_ ✓�
CTIO 5- DES °IPTION 0 PR•PO _D WO° . chec all a® r livable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief D,-scription of Proposed Work: at u #tVS dirMi CL t:. ' I r i 14■
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ unfinished basement ,.., Yes No
Plans Attached Roll ❑ - Sheet❑ �,h°�„��
sal: ewe: U eia tdrO' -hints ing,:..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. Mascheck Energy Compliance form attached?
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
, 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, S'Q v. ',fie ` " 1 , 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.
4004igned under the pains and p nalties of perjury.
Print Name
411 s / is/ad
Signature of Owner/Agent Date
Section 4.
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 ever been issued for/on the site?
NO 47 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO L 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 f/
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
J.'s' City of Northampton g 0
Building Department
212 Main Street - - zi
Room 100
'Northampton, MA 01060 ,t r ' ''
phone 413-587.1240 Fax 413-587-1272 I
6 14 '`.,.;,.: tom '..
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
roperty Address: This section to be completes by office:
1.1 fibun4G+i., s�41 GrQ( 0'� t) 06.T1, ,- Map Lot knit
F//)LP1I CL-/ /CIA O/®(i2— Zone Overlay District
Elm St District ' CB.District '
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: I.J(.icOYN f2 I. I le) )'j'Inkfr )"A-IA i.--e I 6 fi 1o.4„,u� ,yg 1tlaj,2
Name(Print) Current Mailing Addres
,411111l.. -/P -A-4 Telephpi7_ s_ef 9" 3[,�i
Signature 0 `'/
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION CO T5
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. BuildingSdr0 (a) Building Permit Fee
2. Electrical 3,20 f (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) O do Check Number fa;0 6 "' '
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2000-1026
APPLICANT/CONTACT PERSON THRELFALL JASON
ADDRESS/PHONE 600 FLORENCE RD-UNIT#12 (413)584-3876()
PROPERTY LOCATION 600 FLORENCE RD-UNIT#12
MAP 37 PARCEL 022 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid l�� j&
Typeof Construction: FINISH BASEMENT FOR OFFICE&DARK ROOM
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 611 mmission Permit from CB Architecture Committee
•
,S loo a
Signature of Building Officia 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.
`7- O I
RD-UNIT#12 - BP-2000-1026
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37-022 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-1026
Project# JS-2000-1854
Est.Cost: $820.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 1988949.60 Owner: THRELFALL JASON
Zoning: SR Applicant: THRELFALL JASON
AT: 600 FLORENCE RD - UNIT #12
Applicant Address: Phone: Insurance:
600 FLORENCE RD - UNIT#12 (413) 584-3876 0
FLORENCEMA01062 ISSUED ON:5/19/00 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH BASEMENT FOR OFFICE & DARK
ROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough:6141[001 1Zp - House# Foundation:
Final: Final: 9I' UJO?! r Y _
Rough Frame: C5 J.< —
is
Gas Fire Department Fire ace/Chimney:
,
Rough: Oil: Insulation:
Final: Smoke: 3. 0,09
THIS PERMIT MAY BE REVOKED BY THE CIT F NORTHAMPTON UPON VIO ION 0
ANY OF ITS RULES AND REG AT®O,pNS ,
5 S.
Certificate of Occupancy /' Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/19/00 0:00:00 1020 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
•