29-459 (4) rnT
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DEPARTMENT OF DUILDrYG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICE, R'S CONff'ENT SA nON INSURA-NCE A 1 t -D AVTT
(li ccnsccJperm�ttcc) --
\:rith a principal place of business residence at:
(},hone:.') —
r (strI/city/nalcizip)
do hereby certify, under the pains and penalties of peflury, that
( ) I am an empioyei providing the following %vorher's compensanon cove mge for Iny
elnplovees worming on this job_
— (h15uI-eIlCr Comp;_ny) --- --- (Polio,,N ilrr) -- - ({A.fpir don Dart)
( ) I aln a sole proarnctor) general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensavon policies:
(Name of Con!—actor) Datc)
(Name of Contractor) Ojis inane: CompanyiPolucy Numb-r) (pLm,uon Date)
(Name of Conn-actor)--- (Inszlranc: Company/Policy Nuir_tm) (Expir tion Dale)
----(Maine of Contractor) -- (Insurance Company/Pohcy Number) (Exprraiion Date)
(etrach additional-!<d ifnoccnu1 to cn!-u c infxm,%i pcitnin=c to ntl ooan-nc'_o:�3)
al am a sole proprietor and have no one worming for me.
( ) I am a home owner performing fill the work myself.
NOTE:plc. be awam that vrfr-]o boar_ovvcn Nbo cxnplay pcsoni to do m n.�oar�,icdoo or rqa;;wo i ou e d«c11i.6 of
not axxc thrn throo ua.',i to winch the Iw moaner rtndcn or oa the IIouo,�,appu tc uui thcz a. oo(gl= y comidcrcd to be
c�mploycr3 under the wo*ri i oanpcuetim Act(GLI52,s 1(5)�appl ration by a homeowDcr far t beca3c a permit moy-,rd—L<rc
legal O-xtLu of nn employ"under di.o Wodcor&Comgcn wi-ion Act_
I undcrzt-ind chit x Dopy of thii rtit-at m y bo fo.wwded to tbo DcSxirtarsu of inaz V-Yid Arxidca&Offioo of Itrsirw for tha
covmgc vrrtfrcattoo ttnd Unit L•Ilurc to accurc covcTr uodcr scctioa 25A of MOL 152 can Iced to tho iarposiiioa of crimin l pcnattics
coal sling of a fine of up to S 1 X00.00 ar,(Vcx empmonrnc>zt of up to one year and Civil pmxhia in ttx form of a Stop Work Order and a
fine o(S100.00 a day■pint me
Foe dc trj �ui only
Pc irut Number
--
Signatirre of Liccnsec/Pcruljacc
C ERV ICES
...L License,Construction Supervisor: Not Applicable ❑
Name of Licenso Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Ca am,'-
Company Name Registration Number
Address Expiration Date
Telephone-5-'g- v-&5-;F
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §250(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.
'gned Affidavit Attached Yes....... ❑ No...... ❑
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
T N OF'PROROSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemer Windows Alteration(s) ❑ Roofing ❑
Or Doors 91
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[✓j Other [ ]
Brief Description of Proposed Work:—�`���� �� 1✓i�.'y� � ' � �"r � f V�"� I S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
am,plete the llo -till
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
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
I 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 , 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.
gned under the pains and penalties of perjury.
Print Name
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the 1%gistry 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:
z
,City of Northampton
R "Builtjjnyg Department H` CUtli
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212• Main Streeter/�� , t
Z� A�oo�l 100 ,aterllN�ell�xatla tf'y � ,� �
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Nor tA'3tq ,;MA 01062
gone 40 Fax 413-587-1272
APPL Af, CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION.
This section to be completed by office
1.1 Property Address:
71 f`in's, ?"vi&zj �'` Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
key-� � �.Ar✓ 5A)-�
e(Print) Current Mailing Address,
SSG
Telephone
Signature
2.2 Authorized Agent:
�' �a/�(3�� y" �e� r�- N'Via-✓
Name(Print) Current Mailing Address:
Signature Telephone 7-SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
P leted b permit applicant
1. Building Zfl (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) Check Number V
This Section For Official Use Only
uilding Permit Number: MJQ; f �D 2 1 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
71 CRESTVIEW DR BP-2000-0807
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block:29-459 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categ_ory:replacement windows/siding BUILDING PERMIT
Permit# BP-2000-0807
Proiect# JS-2000-1522
Est. Cost: $8820.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Size(sq.ft.): 100 1 8.80 Owner: MONAHAN KEVIN C&KATHY L
Zoning: URA Applicant: Ed Corbett Jr
AT.• 71 CRESTVIEW DR
Applicant Address: Phone: Insurance:
4 Reed Street (413) 586-5192
NORTHAM PTO NMA01060 ISSUED ON:3128100 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & VINYL
SIDING
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: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: &� G-r ��-1 oi ;,
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION
Certificate of Occupancy � signature.:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/28/00 0:00:00 3474 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo