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29-362 4 ob Y x F(iVJf f>T Crifil Of �\T>rzffjaliipfoli 1 -- DEPARTMENT OP DUILDI]\IG INSPPCTIONS = 212 Alain Street ' Municipal Building Northampton, Mass. 01060 WORICE-R'S COMPENSATION MURA-NC E, AFFMAVIT (]icc n Jpc7, 111acc) v"Ith a prulcipal place of businesslresidence at J(, 4jkJ4-0C-V-- - -5:4 &14 tq do hereby certify, under the pains and penalties of perjury, !1121 ( ) I am an employe; providing the ioilowinn co(nnens�.ion cove:::e for Iny employees «o1 ins on ulis jol) (Inszrr�n o��r�n,) (?cL,c r) ( 1 2]71 a Sole n'.OUIiCtOr eilefal C-013iT=of Or honleovtiuet (CL:Ie Ol?e) c_lQ I]cve n1Sea the, conUactors Este below wl]O havC the i0LIOV,7::2 %VOrhzt'S GO 7D°rlS2i10 Dollies- (Na me of COnill ClOr) (Insdr-anc: Como<:nwPo'.icr Date) (Name of Contractor) (Insurance Comp2oy/Pol"c) Namtkr) i xpiran0n Date) (Name of Contractor) -- (Loswancz- Company/PohCV Number) (L-�Piranon Date) (ettaelr adjitioasl 'yeti yr nccaur:to iix_}uc�i if«rI'ioa PQtE to ell ooa7nro-n) �?`am a sole propnetor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plc=-u be nw1 t tYut v tu]o homcrnw ra abo cmplay pcsam to do r iTacL_, r oo a rcpab work on a d>cllice of oo(more th a thrtto tmitr in­lnch the bocaoo�rr udca oc ac ehe©cunda zppucycaant thccto arc oo(gcocr-.Uy oocr:dacd to be employm under the wo;�ccca�>e cn Act(GLI 52S=l(S)�n-WU o-o by a bomvowD r far a l ccx oc permit may cv dmcc Lhc I cVI clams of an omployor under tho work o<<CompomsLioa Arc I undcr:tn d this a oopy of this rust oo =Q y bo forwarded to tbo DoVa im sl of lo�at Ao d=&OtLoo of ttzur-noo for tba coverage virif t3iioa and that f_iltuc to aocurr eovernse ta3der soetioa 25 A of MGL 152 can Irsd to the ialpoSILoa of erimia+!pemllies A0 oomiiting of a fine of up to S 1,�D0.00 arYdlcc aaxprizoamrry of up to ooc yea and cavil pcnrhio in he form of a Stop Wort(Order and a fim o(:S 100.00 a day a{&mal me l For d party xcd use ody `J a PcTmit Numbcr V,�o �✓�� Map:: Lot R �- IpnatiI of Licxnsc Crinittec v" SECTION 8-CONSTRUCTION SERVICES I Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number 7110,10 Address Expiration Date Telephone S-zyz SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§2SC(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. I—Signed Affidavit Attached Yes....... ❑ No...... 11f, afti 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 CTION 5-DESCRI 1ON OF PROPOSED eck all ap licable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Siig'nsCC[ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: !i lT�J l�7 L4 "qla-c�j 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 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. Signature of Owner Date as Own uthorized Age hereby declare that the statements and information on the foregoing application are true and accurate, _ knowledge and belief. Signed under the pains and penalties of perjury. Print Name Si e of Owner/A ent Date Y (r 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 "°. I I -T 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 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: r 7 �; y JUL 3 City' f Northarrjpto Building Departme7 T OF aui DING I 1, 212 Main Street "' ' i"�'`zc • ! �:' 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 SECTION 1-SITE INFORMATION 1.1 Property Address: Tt1is S ian t i completed by o l sr x ,. 1VIapt U � Cv a- tt� Zone Q clay D tract % Etm 5t.t#lisric C k�sf� SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,04ame(Print) Current Mailing Address: l 5-79 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) O Check Number This Section For Official Use Only Building Permit Number; /r� Date Issued: Signature: Building CommissionerAnspector at Buildings Date 219 ACREBROOK DR BP-2001-0012 GIS#: 0 COMMONWEALTH OF MASSACHUSETTS ap:Block:29-362 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofm BUILDING PERMIT Permit# BP-2001-0012 Project# JS-2001-0027 Est.Cost: $2440.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: John Corbett 104000 Lot Size(sa.ft.): 17990.28 Owner: PINARD FRANCIS G&JOANN E zoninp,:URA Applicant. John Corbett AT. 219 ACREBROOK DR Applicant Address: Phone: Insurance: 56 Dimock St (413) 584-5807 LEEDSMA01053 ISSUED ON.7/6/00 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/6/00 0:00:00 831 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo