25A-129 (4) s�
31` Snin Street 't111 ici nl Ii2:l!
Nortlu:ml�tc: . '.1a __ O7t)ful
«'ORI�F,R'S COMPIsNSAT'IO`� hNST1I:AttiCY, At'FIDAVIT
\:'fif7 <. f7tiil�a�)1I p�3CC 0[ i)ll iP„SS�IC',:C
C'lUii�U'.CC_; "l,`UI LaIIi: S1 11
oC
p.
I I
rr.l uxtict:�.❑I::ICO t:c.Lf t- �1.u�' . - --=,•.err:zn..'-� �t,:, ,”" ,.. .. ..., .. >41;- r-.::�_ .. .".... �.-
c:plejc_�uc.�t t}r_��•:;>" ... .__._:i-a ii2(GL1_?.,;(zl). ,� _.:;. a I:-".. ��-a: _..,, ..._
I�_r.:etxnd[fut>u y -!L.•i r :ny tx � ��aj t
-
cv�'cagc vc:illcatioa nndl th_t fill.-c to" ..:c w� " I,I,2 _all Ic.d t�
' rrv� il.l.-r�c _ t,
xituting oIn lur_of u,l to S 1,SM.0 %cr i:.dui T of I!,t i „ - . 1 r.�it _:v;l.c.it `.• r:c(a t, 7< 1'0 � 1
LIw oCStl�-CU a de��as;r.irc.I;n,_
Sli5naturc of Liccn_ JPcrllnttcc ;� �1' I,
SECTION 8 :,CONSTRU.CTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
g e ementTContractor,111 Not Applicable ❑
i Company Name Registration Number
Address Expiration ate
Telephone �Yi dy
SECTION 10, WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit rnust be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance o e building permit.
Signed Affidavit Attached Yes....... No...... ❑
om O�wn�er - emp�l�in
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.
2 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 whicl` 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 _
SECTIONS-€D SCR�PTION OF PROPOSED WORK check all a licable
7 sE# Htl6SP 3+xfr'
v , ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
/ Or Doors ❑
Accessory Bldg. ❑ Demolitionm New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: �a�at/c' R_'-T .sue Qm�I&S
Alteration of existing bedroom Yes y No Adding new bedroom Yes '� No
Attached Narrative r' Renovating unfinished basement Yes V No
Plans Attached Roll 0- Sheet❑
;.apt IfNe�w ho se ��d o a'dtli.ti"o"n/:rto° ezisting� iou"�in>7; comp'he�e' tFie' folJo�"iin>r:
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? fl O
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 AUTHORIZATfON -TO BE COMPLETED WHEN
OWNERSAGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i
�. ,� .,. as Owner of the subject property
hereby auth'rize , to act on
my behalf, in all matters relative to work authorized by this building permit application.
eZ f"0 U
Sign re of Owner Date
w 1�'-, VUAb9_Q-S , as Owner/Authorized Agent
hereby 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 Name
Date
Signature of Owner/Agent
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
Setbacks Front
Side L: R;, L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage 0A
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever bed issued for/on the site?
t
l
NO DON'T KNOW YE8,,
IF YES, date issued: `
i
j
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES e
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:
City of Northampton S atuf`P r <_
'Quilding Department Gurb
212 Main Street Se erg
3 Room 100 Wa er"IW l v = t s
}
"'Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 Plo /Slte.PJa °
' OthertiS eCi
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
x�
Map
cc
f Zone Overlay District
Elm St. District CB District"
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) C ent N wi m, Address:
� f
Signa e
f
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant_
I. Building (a) Building Permit Fee
2. Elecirical (b) ' �timated Total Cost of
Construction from (6)
3. Plumbing I Building Permit Fee
5. Fire Protection _
6. Total = (1 -� 2 + 3 + 4 + Check Nui7 ber
----- �—
T i h e n For Official Use Only
Building Permit Number: ___ Date Issued:__
Signature: --- ------ —
Building Commissioner/inspector of Buildings Date
File#BP-2003-0668
APPLICANT/CONTACT PERSON Harlow Builders
ADDRESS/PHONE 336 COLES MEADOW RD (413)586-0465
PROPERTY LOCATION 69 DAY AVE
MAP 25A PARCEL 129 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REPAIR ROTTED FLOOR IN 2 ROOMS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License 052460
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�FiMATION 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 ssion
v Looj
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.
BP-2003-0668
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0668
Project# JS-2003-1101
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Harlow Builders 052460
Lot Size(sg. ft.): 18992.16 Owner: FINN JOAN B
zoning URB Applicant: Harlow Builders
AT: 69 DAY AVE
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586-0465
Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:2111103 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAI R ROTTED FLOOR I N 2 ROOMS
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/ Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2/11/03 0:00:00 2602 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo