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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
Signature Telephone
Address ExpiratioK Date(
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.
11. - Home OwnerExemption
The current exemption for'hvmcvnmers^was extended minclude one(1) or two(2)families
and to allow such homeowner to oogu8e an individual for hire who does not possess u\iucuac.provided that the owner acts
Homeowner:as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of yor"oo(x)who own u parcel of land on which he/she n,nidon or intends to reside,on which there
io,or is intended to bo,u one ortwo family dwelling,attached or detached otrnomnoo accessory to such use and/c«farm
structures.A Derson who constructs more than one home in a two-year period shall not be considered a homeowner.
Such^homeo,mner'shall submit to the Building offiou/.00u/oonacceptable to the Building Official,
responsible for all such work performed under the buildin2 permit.
As acting Construction Supervisor your presence on thejob site will be required from time to time,during and upon
completion of the work for which this permit ioissued.
Also ho advised that with reference toChapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers»o
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable forporsoo(»)
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other[E�
Brief Description of Proposed
Work:_
Alteration of existing bedroom___—Yes No Adding new bedroom--__Yes —!/_No �
Attached Narrative Renovating unfinished basement -----Yes !!__No
Plans Attached Roll -Sheet
sa,1f N� ht�+usea�ds+�r`ad+�ition to eastirip i>IOUS`Ing;-'complete the fo�lown;a:
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'property ^�A– �CL- ----------------------------------------------------- as Owner of the subject
property /� _
G v % .j �C)" / (c'cl f''J�
hereby authorize ______ __ __ _
- --------------------
to act on my behalf, in all matters relative to work authorized by thi building permit application.
--- – ----------------------------------�'c ( – --
-----------------------------
Signature of caner Date now
O✓�S 7- 1- "- >
(Qo lr j
__—_____ _ _ _ _ _ _ as Owner/Authorized
Agent hereby declare that the statements hnd 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.
--------------------- ------------ ---------------------------- ---
---------------------
Print Name
1Z ` �� '
---------- - --------- "----------------------------------------- – -- -- ----------------------------
–
Signature of Own 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 Specl Permit/Variance/Finding ever been issued for/on the site?
NO i// DONT 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 DONT 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 y
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:
y of Northampton
,
'Iding Department
11� 12 Main Street '
2 13�' 2004 Room 100 `�F%
.?
orth mpton, MA 01060 m ;
13-58 -1240 Fax 413-587-1272
f,,n•e. ; f;... mss. =-=� .. _.� ":'
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
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:
coz-
---------------------
Telephone
Signature
2.2 Authorized Agent:
i•.
---------------- ---- ------------- -------------
Name(Print) Current Mailing Address:
(oZ
- --- -------------------------- -------------------------------------------------
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
L Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Vic/c/G. c J 0 Check Number
This Section For.Official Use Onl
Date
Building Permit Number:_—_--_-__—____—_—_—_—__ Issued:_---____--
Signature: ---------------------------=----------
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0360
APPLICANT/CONTACT PERSON LOUIS MONTGOMERY
ADDRESS/PHONE P 0 BOX 1013 BUCKLAND (413)625-6953
PROPERTY LOCATION 15 CRESTVIEW DR
MAP 29 PARCEL 466 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REBUILD EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accesso?y Structure
Building Plans Included:
Owner/Statement or License 013471
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9Jd1ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Commission Permit from CB Architecture Committee
Permit from Elm Street Co s' n
Signature of Building Official
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
15 CRESTVIEW DR BP-2005-0360
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-466 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perin: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2005-0360
Project# 35-2004-1941
Est. Cost: $2000.00
Fee:i 0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin_ LOUIS MONTGOMERY 013471
Lot Size(sq. ft.): 10018.80 Owner: REAGAN LYNNE
Zoning:UF– /WSP Applicant: LOUIS MONTGOMERY
A !icant Address: Phone: Insurance:
P O BOX 1013 (413) 625-6953
BUCKLANDMA01338-1013 ISSUED ON:9129104 0:00:00
TO PERFORM THE FOLLOWING WORK.REBUILD EXISTING DECK
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: d
Rough: Rough: House#
Driveway Final:
Final: Final:
st' Fr;i7—:
Gas: Fire Department ;�+:.,te/Chimney:
Rough: Oil:
Final: Smoke: Final: Oi< x3(1406 L14i 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of•
CCU anC �L��.�`�SiRnature'
FeeType• Receipt No: Date Paid:— Check No: Amount:
Building 9/29/04 0:00:00 2051 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo