29-314 (8) �Z�wr�T
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F `e (rill of port(Ialliptoil
��czeneht,erfla — - _
u c� DEPARTMENT OP IIUILDrNG INSPPCT)ot,'S
212 Main Strect ' Municipal Buildinc
Northampton, Mass. 01000
`T'ORIC,iz'S CONUENSATION ENSURA—NCF AFFM Wl'
Ia
(li ccus<x/permi ttcc)
t \),rith a pi-ncipal place of business residence at
-- -- -- (phone.')
ty/sta>_cyb p) ---
do hereby ccrtif);, under the pains and penalties of perjury, that
( ) I am an employe, providing the following worker's colnIm Don coverage for Illy
employces worl�ng on Lhis job.
(Losur-✓ Corsr aEv) (Pohc-, Numb--r)
( ) I am a sole proprietor, general contractor or homeowvner (circle One) and have hired
the contractors listed 'below who have the foHo%-YUg worker's coDDen&1-60n PoLcies:
(Name o Co:jt::�ct0-1 — - (In�nnc Compan)-iPclic, NLImb:-,) pirdunn I�atc}
(Name of Contractor) -- Ouu lr2-Doc ComoanyyPolicv Num-rr) (-L.\D lilon Date)
(Name of Contractor) 0-aa anc; Comp.an}•/pope. Number) (Bpiraoo Date)
(Name of Contr ctor) (Insurance ComGaoy/PoLicy Numbs) (L-�pu-,i[on Datc)
(enaG�add;;;beat cad;I nc t,;.^;to�rx!u�;afcrt-iLi eo pcxti'"'�to.11 ooaJr�.v:�)
( ) a sole proprietor and have no one wor};ang for me.
( I am a home owner performing all the work- myself.
NOTE:plea fx c z c +,,.u Jc kxmco v ra uUo cruploy pc-ioci w uo r, -+ , rrau"Qfk on.G..cil of
not mock lt�n tsce i',a in tc�;�ttx l�rmo.,vcr ruido or oa the g-lzp.lz l zppur J= ooalid,c i w be
Aa(GLI52=1(5)�applicilioo try a homoo Der fn e Lrs o p rm t m y c idme r
IeSA--'X-of en e=Plovx under d—Workcl�coQ2par A� -
1 und—tr d tbe%copy ortbii rrjj m m y bo focv,,I d to tbo Dcqu,_)d of InALj-r;cl Ac dc<&OE of Ira.u.noo ror th<
mvmSc-TTJCMLoQ and th_t Likac to pca covc-,�c u ldcr S.0 ioa 25 A of 1.iaL 152 can Irzd to the impositioa of criminal pcua -
bon-ii�u�of n rux of up to S 1-500.00-r0cx c�,.ri of up to one year end ei�i1 pc atj,,in be focm of a Stop Work Order end a
firo of S 100.00.dey t&.imi me
For dcp-ur---`I u,c only
S'Gn1hin of Lic �scc/1'crn iUcc e
G '11N CDNSTftC till
tN 51RIIICS
.1 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
I "IQN 10 °INPRICEFtMPENSi71C1N tNSUkANI;E A #I3AVlT(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.
Signed 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_ Cr) J cc, T,-, cn:�)
New House ❑ Addition ❑ Replacemen endows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes � No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Rollo• Sheet o
N 11
11 111211 11 1 11 1 , Me DMV:am"IMMUMIN
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
V�1' OWNW-A' UTHO, ""[ON t�1"ER I1Y [ N
ill l�tS A`t �"�C� �4P��
N �' t1E�.�"��C��tj�OMN�a PIt FtN!!T
I, G t 0 hI 0 as Owner of the subject property
hereby authorize �� / to act on
my If, in.all matters relative o work authorized by this building permit application.
U-� acu a
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.
Signed under the pains and penalties of er r .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 Speci 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
t,'-�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:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
�t Gfil ttE.INFORMATION
1.1 Property Address: '
sr
16K2,1:-PRQPERI Y OWNERSFIIP/AUTHORIZED AG>EN'f
2.1 Owner of Record:
N int) Current Mailing Address:
� Daeu Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
Item Estimated Cost(Dollars)to be Official.Use Only
completed by ermit applicant
1. Building (a)'Buitdir g Permif'F :
2. Electrical (b) Estimated Tota[Qo t'of
Co€istruction from 6
3. Plumbing Building.Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) h I i nber,
` ' "��ai ,5��ti��n�'c�t",df#ieiaN;tJse Q!tiN
urlct> g Permit lVrmbery bate Issued:
S�na�ure.
Building,
Date
Com�►1,�ssione<flnspector of Bu�l. ings
324 ACREBROOK DR BP-2000-1179
G1S#: COMMONWEALTH OF MASSACHUSETTS
a :Block: 29-314 CITY OF NORTHAMPTON
Lot. -001
Permit: Building
Categor y:replacement windows/siding BUILDING PERMIT
Permit# BP-2000-1179
Project# JS-2000-2065
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 1 001 8.80 Owner: CANON TRACY
Zoning URA Applicant: CANON TRACY
AT: 324 ACREBROOK DR
Applicant Address: Phone: Insurance:
324 ACREBROOK DR (413) 584-8262 0
FLORENCEMA01062 ISSUED ON:6126100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
& REMOVE DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
nspector 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
wilding 6/26/00 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo