36-208 SECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor, Not Applicable ❑
Name of License Holder: ` � � ' 0504-
License Number
'o ? , , S T nP r� � d �� 0J
Address Expiration Date
19)-7
Signature Telephone
imen Not Applicable ❑
VU '-1 L' y t � S N 10tc Stu
Company Name Registration Number
tj
Address t� Expiration •ate
ephone
SECTION 10-WORKERS'COMPENSATION INSU ,x NCE 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.
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 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
7CTION 5- DESCRIPTION OF PROPOSED WORK{check all aRplicable)
New House ❑ Addition ❑ Replacement Windows Iteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other( ]
Brief Description of Proposed Work: mA Uy CL 06 W in 1 '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑. Sheet❑
a# e ouse = , CI it ion 67 o e e e.fail w n
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. =-nlq(-es ions
e. Number of stories?
f. Method of heating? / stove s Number of each
g. Energy Conservation Compliance. '' _Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 10 of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basem or cellar floor below finished grade
k. Will buil ' g conform to the Building and Zoning regulations? Yes No .
I. tic Tank City Sewer Private well City water Supply
SECTION 7a=`OWNER AUTHORIZATION .!TO BE COMPLETED.,.WHEN.,f
OWNERS AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
I, I V�'Iv C� ' as Owner of the subject property
hereby authorize � 1/lt. >v� `W,Ltti L � to act on
my behalf, in all matters relative to work authorizdd by this building per it application.
l
Signature of Owne Date
I, VnW� as Owner/Authorized Agent
hereby declare that the statements hnd 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 Name
Signature of Owner/Agent Da e
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 fi3c&ffi by
Building Depangxdt
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
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:
� _t u f Northampton s
ulld1ng Department
212 Main Street
Room 100
Northam ton, MA 01060 e
> h�Sr3587.1�40 Fax 413.587-1272
PPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1-SITE INFORMATION
r, , This section to be completed'by office '
rt Address: a .
' � f J In ,�° sI�C 1 ' �:Map ' Uni ��
�— C � 26661" - Overlay District ` +
.:Elm StvD�strCct �` •rCBDisfrc _r.—_ "
y-PROPERTY OWNERSHIP/AUTHORIZED AGENT
of Record:
Current Mailing Address:
Telephone
I,A �r(;_ L+
zed Agent:
Current Mailing Address:
il � re T n J I j
Telephone
-ESTIMATED CONSTRUCTION COSTS
Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
(a) Building Permit Fee
iP �.
� (b)Estimated Totat Co$f,Of
i ff
1 �P Construction from 6
g Building.Permit Fee
gal (HVAC)
v 'v" dlr
1 +2 +3 +4 + 5) Check Niniber
4his'Se'dion For Off Use'Only
mgt Number: Date Issue '
x,
>re,al+,L„ .._,...� .,. �k ...,._..,ri ... F.�R h'w a.�at-�''..,.5.�':'�.«.,.,' .fi,;i ���S�,F,p,-r y,:,{ 'N'•t �„b•'7+'�,��'fF, .}3-+�si'�::e�r!w � ��s p.
•ru k' ., �., ,� r ,IC». ,�rdti. 3 r �is � .."+`'K♦+•1^rh��iu Ef,'?�`-v.'.,rty..,:k.V'uK��+, .,..M r,•�.' !�.. '�a.;•.i,'a.i-3''��"''��y X.-�F7•'�'�,{�,« g w4'�t."kFl,."�..�rc ll” JN,R,�� .r..n s.I 5v�;�w. 6,?C .+. k MR �4.`' �� '�!'(�"f�.•. t''_ 'r°
`°I�zt•+a C�y,
�.
Building Commissioner/inspector of Buildings ate
File#BP-2005-0857
APPLICANT/CONTACT PERSON Wright Builders
ADDRESS/PHONE 48 Bates St NORTHAMPTON (413)586-8287
PROPERTY LOCATION 9 BIRCH LANE
MAP 36 PARCEL 208 001 ZONE SR
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: KITCHEN RENOVATION W/NEW FLR&COUNTERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 047146
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9104ATION 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 Co sion
Signature of Building Official 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.
9 BIRCH LANE BP-2005-0857
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-208 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0857
Project# IS-2005-1186
Est.Cost: $14246.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin: Wright Builders 047146
Lot Size(sa. ft.): 65775.60 Owner: SHAW ROBERT A&NANCY B
Zoning: SR Applicant: Wright Builders
AT. 9 BIRCH LANE
Applicant Address: Phone: Insurance:
48 Bates St (413) 586-8287 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:3116105 0:00:00
TO PERFORM THE FOLLOWING WORK.-KITCHEN RENOVATION W/NEW FLR & COUNTERS
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 Occupant 5ienature:
FeeType: Date Paid: Amount:
Building 3/16/05 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
BP-2005-0857
9 BIRCH LANE
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-208 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0857
Proiect# IS-2005-1186
Est. Cost: $14246.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grg ;r Wright Builders .__ 047146
Lot Size(sa.ft.): 65775.60 Owner: SHAW ROBERT A&NANCY B
zoning: SR Applicant: Wright Builders
AT: 9 BIRCH LANE
Applicant Address: Phone: Insurance:
48 Bates St (413 586-8 )87 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:3116105 0:00:00
TO PERFORM THE FOLLOWING WORK.KITCHEN RENOVATION W/NEW FLR & COUNTERS
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:Ji/� — House# Foundation:
Driveway Final:
ti
Final: / 'Final:
� Rough Frame:
1 '
Gas: Fire Department Fireplace/Chimney:
Rough:��� 'j"�<< Oil: Insu:aiiun:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _.
Certificate of Occu anc si nature:
FeeType• Date Paid: Amount:
Building 3/16/05 0:00:00 $65.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo