29-304 (2) t
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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.....
IL Home Owner Exemption
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aw)licable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[O] Other[0]
Brief Work:Description of Proposed j�1u�CT�
Alteration of existing bedroom l l" Yes No Adding new bedroom j�Yes l /(yNoo[}c,J
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6'a. if N6w house and ar 6dditlon'to existing housing, complete the fol'lowina:
a. Use of building : One Family , Two Family Other
b. Number of rooms in each family unit: y Number of Bathrooms
c. Is there a garage attached?-- .
d. Proposed Square footage of new construction. C Dimensions
e. Number of stories? /
f. Method of heating? Lac I �- Fireplaces o 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
_X_ -->A-
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
4
I, as Owner of the subject
property
hereby authorize
to act n y behalf, in all matters relative to work au orized by this building permit application.
Signature Owner Date
I, , Z�my orized
th
Agent hereby eclare at e s atements and information on the or of g application are true and accurate,to th my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature Anerl n t Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size } `
Frontage _ /{
Setbacks Front "' p
......, _..
Side Lill— .. R.� R. _......
Rear
Building Height ... °..°
Bldg.Square Footage __I ___
Open Space Footage % -• ,-
(Lot area minus bldg&paved =, E
....,.
parking)
#of Parking Spaces
Fill:
volume&Location _,,,,, _.,__ .. _,,.. ,,,
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Y& DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Wken permit recorded at the Registry of Deeds?
NO DONT KNOW YES Q
IF YES: Book j Page and/or Document#!
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conse tion Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO\
3,..
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® N0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradi g,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
A
fi
City of Northampton Status of F'entrkrc as � ��
Building Department irrt y fi�e�
212 Main Streetwer �� ,tabii�fy�- �1
Room 100 Wat$T/Weil AVS46O6' ,
Northampton, MA 01060 Two Sets �tructurafi pens 3 „�,
phone 413-587-1240 Fax 413-587-1272 IS1t�Ei�lana
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
bk Map
Lot Unit
Zone Overlay District
T —N Elm St.District ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam .(Print) �,�")t lJ� Curre ailin Address:
Telepho e
Signature
2.2 Authorized Agent:
- 'ABU 1 ; c� � 1CiR
Name Pri t) 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 � � E j V ;E
4. Mechanical(HVAC)
5. Fire Protection tv
6. Total=0 +2+3+4+5) Check Number U L( i
This S on For Official Use OnlyY
Building Permit Number. Date DEPT OF FU LCi;iG INSl` GI10hS
g Issued: N9 t'F ON,h;A 01060
Signature:
Building Commissioner/Inspector of Buildings Date
x
File#BP-2008-0020
APPLICANT/CONTACT PERSON O'LEARY KATHRYN D
ADDRESS/PHONE FLORENCE
PROPERTY LOCATION 406 ACREBROOK DR
MAP 29 PARCEL 304 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fy,e Paid
Kuilding Permit Filled out
yFee Paid q
Typeof Construction:_Install Wood Stove
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR�kIATION PRESENTED:
pproved 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 Commission
A)
Signature of Building Offic al Date 11 1
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.
CREBROOK DR BP-2008-0020
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mgf!BloAe "4 CITY OF NORTHAMPTON
0 -
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2008-0020
Project# JS-2008-000027
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME OWNER EXEMPTION"
Lot Size(sq. ft.): 12763.08 Owner: OTEARY KATHRYN D
Zoning: URA Applicant: O'LEARY KATHRYN D
AT. 406 ACREBROOK DR
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON.71912007 0:00:00
TO PERFORM THE FOLLOWING WORK.-Install Wood Stove
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:
FeeType: Date Paid: Amount:
Building 7/9/2007 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo