29-354 (2) o�ik AjI
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DEPARTMENT 01' PUII_DING INSPECTIONS
212 Maui Street ' Municipal Building
Northampton, Mass. 01060
WORMER'S COMTENSATION INSURANCE, AFFMAM
i,
(Lla;nscrJper niUcC)
��-ith a principal place :�f businessJresidence at
( trc:-Uc It"i ip)
do 'therebv cellll}-, under the pal_hs and penalties of perjul},
O I Uzih employer providing the rollo,vinl, ',�,or'.�,c1�s colnpe.�snti�n coverage ?or lily
employees wor4ing on this job-.
(Insvrancc- Company) -- -(pelicr Nuu-,lbxr) — —(Ei-pirudon Date)—
O I am a sole proprietor, general contractor or l-lorlieovmcn (circle one) and have hired
the contractors listed beiow who have the followir,�,-, orkers compensa ion policies:
(Nnme of Contractor) (Insuranc (EzpiraUOn Date)
(Name of Contractor) (7nsuranec Comca mPoiic,' Ntu.rir r; (Hvcjimilon Date)
-----------------------
I I LLSlIS aI1C C_:m_ nyiFor ic: Nuln� (Ex,:irae
Date)ofContracto;)
(Name of Contractor) (Insurane—, (Eloi7,aion Date)
(altacit id�itioctil tlk-et ifncrc�rir:t�in;3w!c i�tcxmt.'ion pctaiu.u�:a ni;o�:tred,r<)
I gun a sole proprietor :.nd have no one b :ne.
O [ am a home owner perfonnin all the
NO"rF?:yic.:ac tx a�rarc[fat�ti'.:ilc hurxo�~�r_ra�i�ct.;play�-icm to:::;:aulic-.an��ct:.__:.:c'i,�<s tc,air, u�K co a d«clliog of
ncx rtcce ih.n thrco units in t tint lx 1>r, ,zxr rci a ct o;t':u c :,'1 ?Futtc_:rt L`xx e L.:rrt�c raltY vr�ic :-d to be
cn.ployca under the ctib;�'s axrr�za'.i�Act(GL152,_-s 1(S)),n�ts�lier.by a hortconra fcr a Gcr�ix a�rtni:r..��.crdence the
Icgal ct�tue of an o�ploya unc:er tiro W'ortiec'e Cotnpe�ation Act
I un&---tti d that a copy of!lull ctnt--I avy bo fo w'cv�i« to tl�[�cSn L rsii of I u�u i l Act to=�011ioa of(rr uwx for tlm
covcsyge vazificarion and ill--t failure to!-Cure Co010=90 u11-kx scclion 25A of MG1,152 can Ir_d to the i:tr;wsaion of cr. -I pets-11ties
coosuting of a fine of up to S 1500.00 an1'cx-iruprisoumc,i of up to P-M civil paulticl in dr for-of a step W crc Ord--and a
f r r of!;100.0(1 a dsy i£aiusl ar_
-Fcr cSq;uttmt�l u.c arty
Permit Ntuntxr __--
Map',!
Si�naturc of Liart,c 'crrnittce
♦ t
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not A,-;,:Ilc ble ❑
Name of License Holder
License Number
Address Expiration Date
I
Signature Telephone
f9 Register'ed Hom'elmnroveinent'Confractor ;, Not Applicable ❑
I
Compare Name Registration Number
I
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 affida:
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No......
11 �3omeOwnerx: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 buildin-, permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, durin-and upon
completion of the work fc which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (1,iability of Emplovers to
Employees for injuries not resulting in Death) 01-the Masachuset�s General Laws Annotated, you may_be liable for persun(s
you hire to perform work for you under this permit.
The undersigned "homeowner"certifies and assumes resp��nsibility for compliance with the State Building Code, City of
Northampton Ordinances, Stat �d [,_oca %onin� Laws Gild State of Massachusetts General Laws Annotated.
T G �
Homeowner Signature � �—
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows 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 ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a:IFN& louse and or,addition to existing housing,`comp ete',:#he.fol'lowing_
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. f ype 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
as Ov,,ner of the suoject property
hereby authorize to pct o�
my behalf, in all matters relative to-;/ork authorized 5v tivs :auilding perr-nit application.
Signature of Owner Date —_
as Owner%Authorized Agent
hereby declare that the statements and information on the foregoing aaplication are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print me
Signature of Owner/Agent Date —
Section 4.
ALL INFORMATION NIUST 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 vON'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 Status of�Permft�; "w
4 T
+[= Building Department CurbCut
212 Main Street Sewer/Se Tic
Room 100 Water/Well
Northampton, MA 01060 Two Sets.ofStr a
� t
phone 413-587.1.240 fax 413 587-1272 Plot/Sete Flans
Other-Speclfy, 0 ��� .
..=
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be-comp(eted,by office
1.1 Properly Address:
Map Lot Unit
i�.�C:.V«a�n/��', � �., �1���✓_� — Zone Overlay District
Elm St. District______ CB District
SECTION N 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,.a,,,- F nt) �.' rddress-
f` �l
. ig afore
22 Authorized Agent_
�J a r- ,r tint) r t '. ry",r,ilirt,A�dclress.
i
S�gnat ire
SECTION CTf_ON_3_-ESTIMATED CONSTRC;CTION COSTS
Fern
F,,,,;- at r ost Dollars' Official Use Only
,,pie ec' 5, uPrrnit ,I
1 ~uilr�i�� -� jl L3uil�'In permit Fee
I I '
'tmnT; ted J c la! Cost of
oflst'ucr o fm 6 -------
3. P�,Jmbing Building Permit Fee
4. 1�1echanicz! ('r!VAC)
5. Fire Protection
6. -Total � (1 � 2 + 3 + 4 + 5) �Cneck frumDer
This Section For Official Use Only_-_--
a Da[e Issued:___ -----
Building Permit Numb.,r. ---- ----
I Signature: -- ------
Bui!ding Commissioner/Inspector of Buildings
14 AUSTIN CIR BP-2003.0627
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-354 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0627
Project# JS-2003-1033
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contraclo`-
Lot Size(sq.ft.): 11979.00 Owner: MCPHEE NAIA M [; ✓ID H
Zoning_URA Applicant. MCPHEE NAIA M DAVID H
AT. 14 AUSTIN CIR
Applicant Address: Phone: Insurance.
14 AUSTIN CIR
FLORENCEMA01062 ISSUED ON.1/13103 0:00:00
TO PERFORM THE FOLLOWING WORK:W 0 0 l 7 0 V E
POST THIS CARD SO IT IS VISIBLE FROM THE STRI?ET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Fin:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0 k j—/q.p '3
THIS PERMIT MAY BE REVOKED BY THE CITY OF-"';ORTHAMPTON UPON VIOL N O
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy st �.aure:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/13/03 0:00:00 0214 $25.00
212 Main Street,Phone(413)587-1: ,.x: (413)587-1272
Building Commissioner- t". -iy Patillo
6
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