29-371 (2) JAN 5
r mow!/
L;
u'
4�1lAJ f pT -
O O --�—
3 of �n�fl�al�l}lfo>>
c� DEPARTMENT OP DUILDt�\'G INSPECTio?,,S — =�
212 Alain Strcct ' Muoicipal Building
Northampton, Mass. 01060
WOMCER'S CONTPENSATION IIISURA-NCE AFVMAVIT
(li ccus�lpertni ttcc)
\> ith a priricipal place of business/residencc at:
(gTr--U6ty/stair.zip)
do hereby Ccr- fy, under tic pains and penalties of Pegg-y, ?hal
( ) I rn an employer providing the iollow11W Workers cotnoens::non cove,-2-
e nor Illy
eluployces wotijrJg on this job
(ln=u nc2 Corr,v) — — (Pcuc- Date)-
( ) I am a sole proonetor, general contractor or homeov,,-ner (curie oae) a-Dd have hued
the Conractor-s listed below who h ve Lie fo1lowlEg �?'oFke�s C��JeJl_k? 0n p01JC1eS:
(Nam-' of Cont:�cto-) (InR nnc Comoan}vPoiicr �'um'� r) (i=s;>ir uon I�ntc)
(Name of ConlTaCtor) RfiaifaDc;c Comoa-UN'/Polk-V (ExDir,:tion Date)
(Name of Contractor) Clnsufa.nc: Compan}•/PoL-q Ni jmbct) (Expiration Date)
(Name of Contractor) R surmc� Comt-.Dy/Pohcy Numbs) (Expiration Datc)
(enaG+l :::oca1 c'_xc:iI n<ccu:�-to gin:dud;uifor��Li oo pcnzinins to.iJ
( ) I ain a sole propnetor and have no one working for me
I "BI a home owner performing all the work myself.
NOTE:ply be.wire Lt,,ki Jc hc,,Ht,o curplo,pc ow to do c� •r, -r c r air nor oo.G..cAL-
L-,'j in N'j" ttx tkr xw Txr rcvd�a oa the pour zpp etc r two 2 0 _Uy o�:d cd n b
��nioyc-s unG�the-UtS- ;cca::icn Art(GL1 S7=z 1(5)�nppkal) a try n ho;iu fc t Lam„a t�-mit a_y cvi&zrx Ll`c
Ic�l
0---"of ca—Ploy---&c dw Worko(a Coca an po nd
1 ui>dc:stand the>oopy of thi,aiL—ui m y bo forwa.r<!ed to Lb.Dorkr ,of In.'sis:ri�l Aca do g'Offs oo of In-winoo for the
oovcisc va-LriC=Loa'd that f IJtZFc W cccurc covcTn under soc on 25 A of MG 152 an la_d to the of aimiaz.l pcT Lb-
000zu�of a Floc of up to S I X00.00 and/Cx METz-i axix of up to one yc:r c�c�,iJ ,.t'Sa tx form of n Stop Work Ord-and,
fire of 5100.00.day zpinA ar_
For iScq,.uis�il n,<Drily --
V// � Pcnnit NumbcJ
0 G T gyp:; - - Lot " —
St a urL of LiarrscclI'crnuttcc ��
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
€ " E 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...... ❑
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 buildiniz 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.
VHomeowner Signature
t • �
SECTION -.DE TIO OP O (check all a li ab e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: 6
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?
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 R.E COMPLETED WHEN
OWNERS AGENT'dR CONTRACTOR APPLIES'I»OR BUILDING PERMIT
l 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
.. 1
—�--�_- as Owner/Authorized Agent
hereby Clare 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 perjury.
rint Name _
Signat re of Owner/Agent Date
, ' 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 U rT
Setbacks Front
Side L: R: L:/r ;Z R:
Rear (�
Building Height
Bldg. Square Footage .rJ % � ,c�(
Open Space Footage �e�3—� r ,.
(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 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:
of Northampton
4" A ding Department
5 20 ,t 12 Main Street ..
C ` Room 100
- '61 lit N` '�� rth mpton, MA 01060
UN 587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'=-SITE INFORMATION
This,Seolic to completed Y off e ,
1.1 Property Address:
,map
a�
m
Lc��2�z � S S. Zone Urr+�ay�istriGt ��
r✓1
Etn St,Di #r1ct- Eiitr9ct
SECTION 2- PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
�> — _57 2LrJ /
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone-T SECTION-3 ESTIMATED+CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted 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) (0/m Check Number $
This Section For Official Use Only
Building Permit Number:J __ Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2000-1094
APPLICANT/CONTACT PERSON HOOVER CLIFFORD A&GAIL E
ADDRESS/PHONE 15 AUSTIN CIR (413)586-1339 Q
PROPERTY LOCATION 15 AUSTIN CIR
MAP 29 PARCEL 371 ZONE URA �J/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid — 6
Typeof Construction: REPLACE 8 X 10 W/ 10 X 16 SHED
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § _w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § _w/ZONING BOARD OF APPEALS
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 Co on Permit from CB Architecture Committee
OK100
Signature orguilding O'ff t6al Date
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.
. -
15 AUSTIN CIR BP-2000-1094
GIs#: COMMONWEALTH OF MASSACHUSETTS
a :Block:29-371 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: shed BUILDING PERMIT
Permit# BP-2000-1094
Project# JS-2000-1954
Est.Cost: $2600.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 11020.68 Owner: HOOVER CLIFFORD A&GAIL E
Zoning URA Applicant. HOOVER CLIFFORD A & GAIL E
AT. 15 AUSTIN CIR
Applicant Address: Phone: Insurance:
15 AUSTIN CIR (413) 586-1339 O
FLORENCEMA01062 ISSUED ON.•618100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 8 X 10 W/ 10 X 16 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Jnderground: 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 6/8/00 0:00:00 148 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo