29-447 (4) . TON RD < BP-2002-0374
GIS#: COMMONWEALTH OF MASSACHUSETTS
1 tap -447 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0374
Project# JS-2002-0563
Est.Cost: $2800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 12937.32 Owner: SANBORN LOWELL A&LENA D
Zoning:URA Applicant: DE Sheppard Roofing
AT: 26 ELLINGTON RD
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:10/3/01 0:00:00
TO PERFORM THE FOLLOWING WORK:SH I NG LE 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/3/01 0:00:00 316 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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DEPT OF BUILD'•i I�; 4 ,�4 ��
NORTHAMPTON,MA 01060 Other Specify 4 �: ki- ,.
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
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Map Lot ,Unit-
2_,6
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
'` /74-2A'e'L'---• 1.)6 -4/'°1 (I-(' . Telephone
tyre 4 — — --7 ,___ 3 •?2_
2.2 Authorized Agent:
/2/1 --iv 5414/1-41//1-) A G i)t./!v '— ) 7 I t�/Z'6/-'C'.f 77-, t. i / '1 /777441
Name(Print) i Current Mailing Address:
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Signature J Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building l” (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) X,./2`-.L%6% Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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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 situ?
NO 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 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:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
SECTION 5--DESCRIPTION3OF PROPOSED WORKy(check all°applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing gyp%
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 5/I`//2/6Le
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plcr?s Attached Roll ❑ - Sheet❑
6a. If New house and-.oeaddition'to existIo. housin_ comriete'1he folloWio�g:
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
E. Energy Conservation Compliance. Mascheck 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
j. Depth of basement or cellar floor below finishd grn:fe_
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
! C�/L, —,32‘,7-10-04-1 S , as Owner of the e subject pro P
hereby au ao — — r ,/', rr'% I P) rNee-ir--7A (G''t/7-1/C: '2-6).11 to ac
my bey- f, in a I matters relati • work authori 'd by this building permit application.
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- Signature of Owner Date
I, r/' , a /Authorized Agent
hereby declare that he statements and information on the foregoing application are true and accurate, t-of--nay-- -
knowledge and belief.
Signed under the pains and penalties of perjury.
/A`I`L'S
Print Name
Signature of Owner/.:en Da
SECTION 8'-CONSTRUCTION SERVICES T]
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : )1`1 ' GF 6 6 ,5e)6
License Number
24 fi 1b 6 5 > ) ? Ted/o 3
Address / Expiration ate
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Signature Telephone
.`Registered~�NomeIrriprovementContrac{or _, ,,, s,� , ,3,_ _ _ , Not Applicable ❑
7 `ma x /2/) 6°r 24-e" (G 7Y' �:'a,t ) j�; 27 Kc
Company Name Regisr tion Number
7- ( ' L>j l r-(>>:%. ,) 7/ /
Address Expiration Date
Telephone let—et
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 affic
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes 6/ No ❑
X111 Iloiner w ry:xottno :x
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili,
and to allow such homeowner to engage ar individual for hire who does not possess a license, provided that the owner act
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 personi
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
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F Ao tV a Cfixtg 1 Northampton � _.
a a ��,�ti" 6 asaxcI nsctta �_=!
'71 oursavr",
S'!44- DEPARTMENT OF BUILDING INSPECTIONS __���
. 212 Main Street • Municipal Building ' {{=_
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenseripc-mittec)
with a principal place of buinessiresidence at:
n/ , e /e),`1-.�
f,i,_", /4/%_!_i Z . y7-, f77,95 i>7"4)-It f:'Tait._ -(Phone4) 5-2qZ�/?C,
(stz evt/ci ty/statehi p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
s(In ranee Company) (Policy Number) (rxpiration 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 compensation policies:
(Name of Contractor) Cnsr;_;1nce ConpaoyiPoticy Number) (xTiration Date)
(Name of Contractor) (Insu: .nce Companv/Policy Number) (Expiration Date)
— (Name of Contractor) (Insurtia Company/Policy Numbe,) (Expiation Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(attest.MaOcooJ hcct if ncc Bury to include infortnatioo pertaining to all c 2rad.ors)
i
am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself:
NOTE:plc,sr be aware that while homeotcneta who employ pazo=to do tr.irrt n.nr-,mmtrucioo cr repair work on a dwelling of
not more than three units in whin].the homeowner rcIddes cc co the grounds appurtenant thereto are oot gcaerddly considcrtd to be
employee u»dcr the worker's ccrrp Betio Act(GL152,s11(5)),application by e homeowner fora decree or permii may cvidcnoc the
legal rtuuu of an et ployer under the Worker's Compeceatj0 Act
I understand that a copy of this ctatemeat may be fcrv:coded to the peps:tacaC of Industrial Acadrnti Offioe of Inairwoo for the
oove rage vctificaiion and that failure to aoatre coverage under section 25A of MOIL 152 can lead to the imposition of criminal penalties
coasiuiag of a fine of up to S I,500.00 and/or iraprisonalaat of tip to on yter and civil pcnalties in the form of a Stop Work Order and a
fine of 5100.00 a day against can
1
For ckpirttn^nial ttso only
,, / Permit Number
tr—er./ Mapg Lot#
Signature of Liccn r/Permittee.. Ds e
4116
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.f,teen,"
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