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PERMIT APPLICATION CHKK LIST
PAGE ��' PLOT 253 ZONE
YES NO DATE
1 . ZONING FORM APPLICATION
2 . PERMIT APPLICATION L-
3 . OWNER OCCUPANT STATEMENT LIC. # IF NOT
4 . 3 SETS OF PLANS PLOT PLANCi
5 . NEW CONSTRUCTION
6 . CURB CU
7 . WATER VAI I T FORMS
8 . REMODELING INTERIOR
9 . ADDITIO
10 . ACCESSORY STRUCTURE
11 . SIGN / AWNI
12 . PERMIT FEE - CHECK ONLY - MONEY O DER `�-- 31D z
13 . SPECIAL PERMIT REQUIRED WITH DEED IF APPLICABLE
14 . UNDER SECTION 127- CMR 780
15 , FORM A
16 , FILL
COMMENTS :
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SECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Superv}i-s�or:� , (,, Not Applicable ❑
Name of License-Holder: Q oft 1 1� LIJ� ► r 1, > 0+5075
License Number
up
Address Expiratiob Date
Signature Telephone
Not Applicable ❑
V�J u tv _ plc. 10i5� �
Company Uhme Registration Number
Address Expiratio Date
La-�:E
Telephone too
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 mrformed 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. DESCRIPTION OF PROPOSED WORK(check all amicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ]
Brief Description of Proposed Work: ReYI>stt kk E'AC 6A(, �-CCf- 1)J SCYc't'►'1 ',V\ pJckce 1`�} Ylti
Alteration of existing bedroom Yes--Y-- No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes X No
Plans Attached Roll 0• Sheet 0
' " p a I �4.housz o dtion - 9tnFmoe e hoilo n �
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: U Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimens' s
e. Number of stories?
f. Method of heating? Fir ces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction
i. Is construction within 100 ft. etlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement o lar floor below finished grade
k. Will buildin nform to the Building and Zoning regulations? Yes No .
1. S c Tank City Sewer Private well City water Supply
SECTION 7a` OWNER AUTHORIZATION-'TO BE COMPLETED WHEN f�
OWNERS AGENT OR'CONTRAGTOR APPLIES FOR BUILDING PERMIT
I, t ,r� V as Owner of the subject property
hereby authorize d �v ` ►`t 1 �� T �I l( �V S to act on
my behalf, in all matters relative to work authoriz d by this tuilding permit application.
Signature of Owner Date
I, y1 21A t1 �[ W as Owner uth ized A ent
hereby declare that the stateme s and in rmation on the foregoing application are true and accurate, to he best of my
knowledge and belief.
Signed under the pains and penalties of perjury. .
Print Name
::�(a,
Signature of Own gent Date
s
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 3b1 601� 13 (
Frontage
Setbacks Front (p2.5, 2ja t 3 d
Side L: b- R: L: iL - R: �ZJ
Rear i� f t 1 �} q9
Building Height -50' ,�r
Bldg.Square Footage °L► % 2K1 q p ac (P I.
a
Open Space Footage %
(Lot area minus bldg&paved � �w• � �� � ?� ��� ��— � .
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 X— 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:
City of Northampton a s;cf; t
Building Department V. .t3
212 Main Street 5e e I.
Room 100 �e,� `�
Northampton, MA 01060 e
phone 413.587.1240 Fax 413-587-1272 0 t x
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH OR TWO FAMILY DWE ;
I i v J N 2 tl 1_vl�v
(ice
SECTION 1-SITE INFORMATION "x'11 L TiL',NS
This sSction to Ge-cumpTet07- i of#�sa--4z
1.1 Property Address: ////may
Map 5 Lot Urnt <'7
�,e5/,,�1//�� M J/�
Zone Overlay District
Zone
Elm St�Diistrict CB Dlstnct
St. _
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name rint) /N ����� _ Current Mailing A dress:
Telephone
Signature l lD tp
2.2 Authorized Agent:
G rS�'1 ( -t6 jl ) �T'-S S
Name(Print) Current Mailing Address:
Signature Telephone
j SECTION 3-ESTIMATED CONSTRUCTION COSTSL --
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost-of . .
r�jtu Construction from 6
3. Plumbing Building Permit Fes
4. Mechanical (HVAC) t ``` :�{
_
5. Fire Protection �' M '_'`
6. Total =(1 + 2 + 3 +4+ 5) — Check umber:
•,. r.:. ^ _. R, L� _ _
fir.. ,
fi
his Section or'Official Use'Onl
'. t ..ti 5 4 y 1. '• ��S '7G} 1�} ��'.. .. �•
y'.. } ` Ni'� �a ISSUe �wl„° -55."f.r'LA.r` w N'�`4•..�. B'y'Y"l1. � •�s4u
86llding Permit Number s _ to
,,.. Lt
%'� ���''� �y'f„•�k�,� .,.�1 y, �,jF�r tiY���,,. l��t.'w'r' d�C 1:5'm' .k.�'>.r. _ .;t, 4.!:*,�F J'N>w-°r 'Pa .I_��YA3•IG;:,4 .F •�1:W .x»d• ��_ i y°-'
^c. -ru'L t� a K ,.Y'"'? 3r'>;.�, I Y� 1 �,+ ,�Sr.,+� � dint.` �i!�sa"y�� `{���ti '�S.��Ay��t `y �'>•xd �4 p
' ,j{
Signature
�... }_ Building Commissioner/Inspector of Buildings
at ,.. a M w N� , . ? -
File#BP-2003-1214
APPLICANT/CONTACT PERSON Wright Builders
ADDRESS/PHONE 48 Bates St (413)586-8287
PROPERTY LOCATION 43 MAPLE RIDGE RD
MAP 36 PARCEL 253 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid /, ,J
Typeof Construction: EXTEN6 EXISTING DECK&SCREN IN,ROOF&SKYLIGHT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 045075
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF( IATION 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 Str Commission
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.
r
BP-2003-1214
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1214
Project# JS-2003-1884
Est. Cost: $15573.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groo: Wright Builders 045075
Lot Size(sg.ft.): 128502.00 Owner: OWEN CAROL L&MICHAEL K POSNE
Zoning SR Applicant: Wright Builders
AT.• 43 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
48 Bates St (413) 586-8287 Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON.6/27/03 0.00.00
TO PERFORM THE FOLLOWING WORK.-EXTEND EXISTING DECK & SCREN IN, ROOF &
SKYLIGHT
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 Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/27/03 0:00:00 15923 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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413-586-8287 FAX 413-587-9276
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