36-135 (2) SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not�Applicable ❑
Name of License Holder:— 'f '��`— �l— C,r)!� 16 d
Licember
Address Expirati n Date
Si r _ Telephone
J
9,l� /istered Home Improvement Contractor-, Not Applicable ❑
? e n aels- 7
Compa Name Registration Number
Addr s Expiration Dat
6 S'-t C==_-) --)2d /y'4 Telephone 3�4' lV—
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 faun
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other[[--3]
Brief Description of Proposed
Wo k /�G� �� J �� ��� `a�� •.
Alteration of existing bedroom Yes No Adding new bedroom Yes VNo
Attached Narrative Renovating unfinished basement Yes V-- No
Plans Attached Roll -Sheet
6a: if New house a' d or addition to existing- housin-0, corn fete the following:
a. Us of b i4quare e Family Two Family Other
b. be of each family unit: Number of Bathrooms
c. I t er a Cached? /")
d. ro sed otage of new constructio n. �y Dimensions L U
e. Number of stories?
f. Method of heating? l v 7- Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance.T/(1.l Masscheck 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 L/�o
j. Depth of basement or cellar floor below finished grade _�,-At ,tea
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, rS (.i C -,- - /'� �� as Owner of the subject
property
hereby authorizer -
to agcn my behalf, in all mat rs relative to work authorized by this building permit application.
� L�-tee_
Signature of Owner Date
I, -CQ _ ��� 'S as Owner/Authorized
Agent hereb 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 perjury.
Print Nam
nature wner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size !�—7 7 „ . /S-7 .ZC{ S i
Frontage
Setbacks Front
Side L:�lG.S R: 5�.5 L: R::MIS— � �{
Rear 7Y t SAS
Building Height /(0
Bldg. Square Footage 13?- % 2r%Z �►
Open Space Footage �% '(rte
(Lot area minus bldg&paved 136 y !3��,L/ j y r� Q
parking)/
#of Parking Spaces
Fill:
volume&Location G'
A. Has a Special Permit/Variance/Finding eyer been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:,`
IF YES: Was the permit recorded at the Registry-of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 F'ON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
... ..... ...... .. . .......
C. Do any signs exist on the property? YES 0 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:
E. Will the construction activity disturb(clearing, grading, excav ion, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES IS
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t
Department use only,
City of Northampton Status of Permit:
Building Department Curb CuttDrIV' Perm'it
212 Main Street Sewer/SepticAvailabilityr
Room 100 w6tert eit Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans:
r,
.__�__ - city �
APPLICATION TO CONSTRUCT,ALTER,REED R- �A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION l MAR 19 2M I1.1 Property Address:
T is section to be completed by office
2-4 -ce r!c �1 �>` �-� _ �ap�, mS Lot Unit
,tea L Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Bruce and Linda Zeitler 264 Brookside Circle Florence ma 01062
Narm��7e,(Print) �yOy` Current Mailing Address: 1-413-584-4252
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
4naoffe Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building C (a)Building Permit Fee
2. Electrical / �j �� 0 (b)Estimated Total Cost of
b Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) e
5. Fire Protection
6. Total=0 +2+3+4+5) CCU.- Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0759
APPLICANT/CONTACT PERSON STEPHEN D ROSS
ADDRESS/PHONE 36 SERVICE CENTER RD NORTHAMPTON (413)584-1224 Q
PROPERTY LOCATION 264 BROOKSIDE CIR
MAP 36 PARCEL 135 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 20 X 24 DET GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079160
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Building 1ci 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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
iO+BROW=CIR BP-2009-0759
GIs#: COMMONWEALTH OF MASSACHUSETTS
Aik�t�� CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0759
Project# JS-2009-001128
Est. Cost: $24800.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq. ft.): 15768.72 Owner: ZEITLER BRUCE A&LINDA J
Zoning:URA(100)/ Applicant: STEPHEN D ROSS
AT. 264 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTON MAO 1060 ISSUED ON:313012009 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 24 DET GARAGE
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 Sisnature:
FeeType• Date Paid: Amount:
Building 3/30/2009 0:00:00 $96.00288
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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264 BROOKSIDE CIR BP-2009-0759
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block:36- 135 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: BUILDING PERMIT
Permit# BP-2009-0759
Proiect# JS-2009-001128
Est. Cost: $24800.00
Fee: $96.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: STEPHEN D ROSS 079160
Lot Size(sq.ft.): 15768.72 Owner: ZEITLER BRUCE A&LINDA J
Zoning URA(100)/ Applicant: STEPHEN D ROSS
AT: 264 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
36 SERVICE CENTER RD (413) 584-1224 O WC
NORTHAMPTONMA01060 ISSUED ON:313012009 0:00::00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 24 DET GARAGE
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: Rougher-j/2�)/��/,�j��-f�ause# Foundation:6;<
Dr�vewsy Final:
Final: Final: S
Rough Frame: Ok
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: OK 042,8109 LOWS
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc signature:
FeeTvpe Date aid: Amount:
Building 3/30/2009 0:00:00 $96.00288
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo