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DEPART1.1E1JT OP BUILDING INSPECTIONS
212 Main Strect ' Municipal Building �.
NorthampLori, Mass. 010GO
CCMIPENSAIZON MSURA-NCY, AFFIDAVIT
11i ccuscrJ��rin�ttcc)
v.rith a phnspA place of bilsinesdresidencr at
do hereby cc[-Lily, un(icr the pawls and penalties of perjury, .h
( ) I :-n an employer providing the following workcCs comp nsz,on coverl;e fol Intl,
eluplovcc� wol:�ns, on tlis job
( ) I am a sole pronrictor, general contractor or honleovvner (ci;c'e 011'1 and llEvc hued
the convano"S OR Now who have IN fol vmg 'woi i&s coi"i):.: Swn pC ues
(NIa11]c 0;-CC,:.:.'c.0
��ali1C Of CC➢i?aCioC) �nS.L' I]C:, Coulpanypohm, Nlil] W) (mo:won Dot--)
(N2me otConractor)— Qnsulanc Compaoyll)oGcO. Nus�b )- (ENpII uo❑ DatC
Q�2�c of (v t� r) �Insuranc� Collarr,�lt'olic� i uml�r) �>>.1,t�ation Da1c)
( ) I am a sole prophet()[ anti have n0 one %vor king for me.
( ' I and a hon-le owner performilig all tht wor! myself.
Noll plc M c•h�.c Li �'.uJc t�c:va�iwn�i�ca,play pczon:w d��4,ci�n�ci.r:r;��_�c.r:;-cur••uii;cn�G..d1^�of
on<n.-at tic t!�ca �in uiu;e'�ttrc b oc o(i the Qoeuv`�z♦p:rY.crun5 t1x-�n c.-c ox���.1?y oec�id�cd to ti
��lcyc)wN-' �a t.ai � lim pc (GL152---1(5)�n{pl LZ ion try e 6o no�anc fa;c L r•: mp n y dux
I<sal aaac of cn c iloyn unC It-We c!r Coa2po—,L. a,?-C-
die>Dopy of thL mi _y bo for-xnrrl.ud to 0_DcFxJmxsL id N_""OS_of W___f ttm
covmg-c vclif c--t.00 cfld th-1 f-iltuc to t« co��,uzk�scctioo 25A of MGM- M can lad to jh-u,^r�slio.�of rvwri.l pcaillin
.. ooaiutmg of n fur_of ttp LOS 1 500-00 a:b1/or cn;rriwcun-.>+o(up W pcu.t'.ia m tic f,of n Stop Wort;aid enc e
Grp 0(5100.0,d-,y ❑i-
oril).
< � , i � t" Pcnnit Ntuntxs
—
Sit'nature of Li<xn_,rcdPcrmiltcc
ti
SECTION Z-CONSTRUCTION SERVICES
-0� —
4, Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone_
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,
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.
JAigned Affidavit Attached Yes....... No...... ❑
W OW41",
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 buildins!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
TO QF P OPO ED WORK check all a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. 14 Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other [ ]
,-,-grief Description of Proposed Work: t ! r 4 r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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 11
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
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.
igned 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
arz:)
Lot Size
Frontage
Setbacks Front
Side L: R: L: R
Rear
Building Height
a
Bldg.Square Footage % J—p
Open Space Footage %
(Lot area minus bldg&paved 3�
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 _
4 � _
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 NOS
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:
QNorthampton es
B I g Department
3 0 2000 Main Street
,
om 100 ��#
DE1 T OF 8UILDlNGh6S _
dam ton, MA 01060
240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'i 1-SITE=INFORMATION
1.1 Property Address: Thts SetrortG be 9"M id yoffiy
F .
''
,AJ r
Zone erlay Des#r�ct
Elm St.Diptrlct, CB DPstrl t
SECTION'2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
cf
Name(Print) f Current-aiIipg-Address: r
i
_ Telephone
signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com Ieted by ermit applicant
1. Building c _ (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
This Section For Official Use Only
Building'Permit Number: 4&k2 Date Issued.:
signature:
Building Commissioner/inspector of Buildings Date
File#BP-2000-1210
APPLICANT/CONTACT PERSON BROWN STEPHEN A
ADDRESS/PHONE 74 CONZ ST (413)586-6648 Q
PROPERTY LOCATION 74 CONZ ST
MAP 32C PARCEL 130 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled ou
Fee Paid
Typeof Construction: MOVE EXISTING 10 X20 SHED
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 C ssion Permit from CB Architecture Committee
7 moo a
Signature-of-Building 6fficial 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.
74 CONZ ST BP-2000-1210
G1S#: COMMONWEALTH OF MASSACHUSETTS
ap:Block: 32C- 130 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-1210
Project# JS-2000-2103
Est.Cost: $600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 221 28.48 Owner: BROWN STEPHEN A
Zoning: Applicant. BROWN STEPHEN A
AT. 74 CONZ ST
Applicant Address: Phone: Insurance:
74 CONZ ST (413) 586-6648 0
NORTHAMPTONMA01060 ISSUED ON.7/6/00 0:00:00
TO PERFORM THE FOLLOWING WORK.-MOVE EXISTING 10 X20 SHED
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/6/00 0:00:00 909 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo