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DEPARTME2.TT OF BUILDING INSPECTIONS
222 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKERS CONrrENI SATION INSURANCE A_ F ,.�.vl.T
i
Cl(C7II11ii •^.) _.__.---
"vith a principal place of businessJre:i e�nce t:
do licrc:by ccrw ;ti U11,0ti- dic oz;ns and pcn hues Oi pcgury, Cilflt
O I am an employer providing the �0110%vint V1,01,cr`S colnnensabon coves .e for my
employees Wo6drig on tins job: v
jmS,,1 cn_Comp:m") i clic;Number) - (Ex#mz�bn Date)
! ) I alit a sole proprietor, general c-mirc`cr jr hoa�c o��xler (c4 c±e one) and, have ilitez
the contractors listed beiow vvho th Oil ;n P� ii.
.y ork Scot pensa�onc,e_ces_
(l,:ame of Con=cto')
: sL m.
cm tcc Cerr._....,,,Pclicf Nttm>Yr) x, rr: ca Date)
(Name of ConLrctOr) (711SJ P.0 CoMz:vpc-!ic-,, Namur) (E,:pimiion Daie)
(Name of Coatnc10r) — (Ia7j7 ace Co -a�yiPo!ic. Ntuvb r x T uo
- ) irate)
- (Name of Contractor) --- (Iasuranct ConIT-.a�y I oUcy N°umt,_r) (E;:i:,*!.mua: Date)-
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cmploycl un cr tar wcckezz cc •=tat:r_n r r(6;;.,152:,•:(51;,a,:it_^..!ic::by a hoc•icoa-.rr fora Lcc x a p-r::;::c crtic
legal Ratus o(an o�>loyx under t n Wcvicer<<02 _.+.Lion AeL
I ut&--..ixad the a copy of tli, bo fcK,,vddf to LLA[yt uu rn of In 6 s ri Mi as:�Ci?o0 of is�.r o for tlx
ooverage vcrificadoo and th_t C-ulum to t—Lr: ISA of MG1,152 can Ic--d to the mposiiio f cf c rte; .t pccsl:a
eomistyna of n fLLx of up to S I .00¢: Y a to rr.' er.j C V11 peSlzlLe2 in do C(nn cf a S!r.,`,VCAr Oni-
5r oCSlo0.o0¢day tgtiml Ins .
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New House ❑ Addition Replacement Windows Alteration(s) ❑ TRoofing ❑ .
Or Doors ❑
Accessory Bldg. ❑ Demolit-son❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: t7 (far
Alteration of existing bedroom Yes_�No Adding new bedroom Yes _ No
Attached Narrative 0 Renovating unfinished basement Yes ` No
Plans Attached Roll 0-Sheet 0
e o n o c.a twon o exrstin urn c trt o no£
a. Use of building: One Family 1/ Two Family Other
b. Number of rooms in each family unit: + Number of Bathrooms_��
c. Is there a garage attached? � ff C�
d. Proposed Square footage of new construction. bimensions I Z (' 0
e. Number of stories?
f. Method of heating? k Un-( Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction oa- c
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 C3
k. Will building conform to the Building and Zoning regulations? t"'O Yes No .
I. Septic Tank City Sewer Private well City water Supply
ON TO BE COMPETED 1�f�HEf �'
QW.1�[E CO GTO2 APPLIE5'FORB L1 G PBFt� !
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorizer) by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the 9tatements 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.
a,
Print Name
Signature of Owner/Agent Date
City of Northampton
udding Department
212 Main Street
;i Room 100
thampton, MA 01060
JUL 2 2 aR ae 387-1240 Fax 413-587-1272
i
DE �; t �ONS RUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S!ITE INFOEtMATION
this a t`io b °qY`me ffic .
1.1 Property Address:
S 6 A I keno-hun ir. �i o
�Ma L s
EImS:tDistr�ct GAB Utz ct w _ �z
- _
SECTION.2- PROPERTY OWNERSHIP�AUTHORIZED AGENT
2.1 Owner of Record:
OVIV/114 1ja n �(
Name(Print) Cur nt ailing ress-
rlj ' 71
Telephone
ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECT]Ot2 - ESTIMAtED CONSTRIICTfOIV`CaS TS
Item Estimated Cost (Dollars) to be Offi. I Use C7nay
completed by ermit applicant 4.
1. Building
(a) Building Permit Fee
2. Elec,rical (b) Estimated Tota[Cost:of
Construction from_.6`
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection v
6. Total =(1 + 2 + 3 + 4 + 5) JCheck Number
This Section For.Official Use Only,
Build n Permit Number:
g _ __.:. _ ` <Date Fssued:
Signature:
Building Commissioner/Inspector of Buildings Date"
File#BP-2004-0079
APPLICANT/CONTACT PERSON MYETTE RUSSELL J
ADDRESS/PHONE 86 RIVERBANK ROAD (413)586-7126()
PROPERTY LO m
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid 7 , �
Tvpeof Construction: CONSTRUCT 12 X 20 CARPORT ON EXISTING PAVEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accesso Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PV&SENTED:
Approved V 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
N 0Z
V-1, Permit from Conservation Commission Permit from CB Architecture Committee
/Permit from E16 Street scion
'Iry
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.