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29-463 (5)
D }� it of Northampton i ng Department � 720 Main Street 'Room 100 DEPT OF BUI No that pton, MA 01062 T 1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectiod0o be completed by office 1.1 Property Address: h y yVld 301 n rx y{ Zone Overlay Dis#t►cY Ely St.District CB;District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: S7 i'57.J Name(Print) Current Mailing Address: Telephone 51 gl�_ ;7Y32-Signature 7 2.2 Authorized Agent: f�/ 00,1Caa-77— 4?. /V Name(Print) 011 Current Mailing Address: 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 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 + 3 +4 + 5) a s Check Number q 1 � / This Section For Official Use Only Building Permit Number: g 8� }� FDatelssued: Signature: Building'Commissioner/Inspector of Buildings 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 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- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacemenj,,Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other [ ] Brief Description of Proposed Work:Vtoi4I 51CIIAI 02 �n�-}Ry .17bo25 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ . Sheet❑ Eau If N°ew ho ise and o°r aclditioi toe is it -h�o r rng °compt;ete tl` WE WON,': 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? 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, , 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 alrlr r-e_ — c] 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. Signed under the pains and penalties of perjury. Print Name 2� 7 7-zo�� Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES j 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ C0 R(3c.r,;- Gloms a2w //G o109 Company Name Registration Number t-1 &d S�' S-i S- o-Z- Address Expiration Date Telephone J�By X057/ 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...... ❑ sl..,} Hvmes,.Owner E eM0 io> 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 i cif1Lt� 4 "� � �i76Ar11115(tf6 DEPARTMENT 01' ©UILD0\1G INSPECJ'IO1JS =i 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORICER'S COWENSATION INSURANCE A t AVIT - (li�Flsedperml flee) %vith a. principal place of business/residence at y W -sue-N/�✓ -- o/a�d ------ r��n�-ane�:)JWy1�?/ du hereby certify, under the pains and penalties of pe:Jury, l ::m an empiover p rovldin- the followlnS' vvUrkei_S COMDCI1S Uofl coverage for Illy Cinpl(;"!c-CS Wol L.11lg oil 11115)oi) iIl:nl >n�� Cotn(;anv) (Poli(-v Nur]lE>cr) (l=1-pirtion Da?i,) ( 1 l ,_ln a sole proprietor, genera contractor or homeowner (ejcie one) iind have lured the contractors listed below who have the follov1v'1ng worker's co rntlensiion policies (N11131C Of 1_o.1"-nc.'D-) (lltsnnnc� COfllD7;7}'/1�G�lC,' ;�tl1iI1C'r:) (I✓Aplfill]QI1 Datc) (N!111C of 1_olliI,.C:or) O11511rIllG;: Coilwa;ly/Pohc" i�111 �.�I) (ExpimUon Dale) (Name of Contr'ICTC'-) (Insurance Conipil y/T]ol;cj N llr r•_l) lExptrtlo❑ Date) (Nanle of Contnctor) (Insurance Colill ].uy/Policy Number) (Expiration Date) vk1;t]c-l.l s!X,f Il[]- <.,tl:y u,�tY:]U(� l f.?rl:lltl ULl Fc t.-Ing*to SLI CY RSII(;O.']j (1�I am a sole proprietor and have no one working for me O I am a home owner perfor7lund all the work fnyself. NOTE plc:-s,be av am Liu!w!nlo h(-,—C nn"wbo crnplcry perwm to(So ma=cn.utcr,axr7u Lon a terra r wo X oa 1 d.erring of I-oxxe th-n thmo uru i in wfilch d-txym-r, qxr rriidc3 or oo the&tcxuxb appurtcnw3l tha-Tto arT Lxx Caxrally coatidcrcd to be crtploycr3-Xi-0-wvt-k&m ax:3=c Tian Act(GLI52_z31(S)} apyllic:i6on by a homco—ja fur a bccmc or pernut tray cvi&rxx the lcSAl rtatlu of m xrvloyx under dln Workd.C'oaxl,alioa Art._ I Luxicrxxlnd dw a copy of this rtxt—.-a—y Lo forty—dc d to tha DcVwtu.-d of 1rN&1rri4l Amdnn'Y OfL_of Ira+lrarxx for the wvcrl.nt`rmficalioa and that f=lu c to soatrc covcrl.sc tmdex It,-Xion 25 A of MOL 152=lmd to tho itttpositiat of--!"pcaaltia ooau-"Lng of a tint of up to S 1.300.00 nrxifor ez txrff Of"T to aoc year and civil pcsnitia in the fate of a Skip Work Otdr and a fires-at SI00.00 a d_y Lgaul-1 tm For drwhlrrYsl ulc oily Pcrmlt Nkllnbcx --- - -- -- Si};uahtrc t�f I.iccrlscc/Pcrmittcr - -- TSI�i-_ - - ---- - ---- y� " A lop, y i i � ' ?fl��'! } � r .7fv( a!'�:t � v �; f i I ,. i r ,. . : A ( , �,, . ._._� � .. __.. ---- I ', 4.Y �:, ... �.. t .. � ��", Y" 1 4. � , r �_ _ .,. t. �' i i ,i _. • [, v � �.. ♦.. f.. � M� '. �.;.;.' �' y C .... —� n I i�