29-323 (3) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
-----------------------------------------------
Signature Telephone
S.Realstemd 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...... ❑
11. - 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 buildine 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,Stat d Local Zoning Laws d State otMassachusetts General Laws Annotated.
Homeowner Signature 7 an
"
x",
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed - Y1 ii a l
Work:_ Oe_l2lAed- iAJ'at s.
Alteration of existing bedroom---Yes---No Adding new bedroom ____Yes Yes No
Attached Narrative Renovating unfinished basement -------Yes _—_—No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing, complete the following:
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.
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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.
Si�ned under the pains and penalties of perjury.
Print Ame — — ----------
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 Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT 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
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:
S
Depathnent 100<xtly ;
City of Northampton Status of porn
Building Department Curb Cult/Driveway Permit
212 Main Street SewerlSsptic Ava"*
Room 100 Waterrfftff Ava"
Northampton, MA 01060 Two 60%Of Viral Pans
phone 413-587-1240 Fax 413-587-1272 Plotme Plans
Other Specllly
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_
:355 Pore brejoL Drive — Forepice zone �Overlay District—
Elm St.District_ CO District--
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name rint) Current Mailing Address:
P- 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
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) Check Number
This Section For Official Use Only
Building Permit Number:_ b =LC�_^ // _- Date
Issued:
Signature: -----�— V
Building Commissioner/Inspector of Buildings Date
1 BP-2003-1112
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:ELECTRICAL BUILDING PERMIT
Permit# BP-2003-1112
Project# JS-2002-0657
Est.Cost: $1500.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grout: Homeowner as Contractor
Lot Size(sq_ft.): 22302.72 Owner: LAIZER JAMES&DEBORA
Zoning:URA Applicant: LAIZER JAMES & DEBORA
AT: 355 ACREBROOK DR
Applicant Address: Phone: Insurance:
355 ACREBROOK DR
FLORENCEMA01062 ISSUED ON.615103 0:00:00
TO PERFORM THE FOLLOWING WORK.-roof over one layer of shingles
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• Receipt No: Date Paid: Check No: Amount:
Building 6/5/03 0:00:00 2402 $0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo