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25A-143 (7)
�Yttn�•rnr .r.. Gii-L ref �\Tarflizalilptot_l e $Zasattritasrtta' i i DEPnR.TMEWT OF BUILDrNIC INSPECTIONS ` 212 Main SLrcet ' Mum6pal Building NorLhampLon, Mass. 010GO ` `ORMER'S CO'NOENSA'TIGN 'MSURA.NCE A T • rb 1-I (li ccnscc/perrni tare) .2.rILh a principal place of businessfresidence at: - vt)r S t r�P"� wC (phone:'} �3 C- 'f (st =A1Cityisratclrip) do hereby certify, under dic-pains and pcmlLies of perjury., that ( } I tam an employer providing the folloxvine'«ortices comoens-zoor, covera- for my i employees woriaag on this job: i r (Isusut-_n=.Comm) (Pale 1,,'.u-*abcr) (expiration,D2=) j ( ) I am a sole proprietor, general contractor or homeoivimer(ci c:e ore) aao have hired the coda-aCiors fisted below who have the iollOwing worker's comperszaon pakles: (Nam: of Conc ncwo (Iasuranc-- Compa,yi?oUcc; Numbn.) (ripiaeen Dam) (N me of Coatrctor) (Insurance CompanvrPolicy `uraxc-T) (Extrim6on Dale) (Name of Cosrraetdr) (Insurance.Company/PoUc Numb.-j) (Expirraos Dale) f (Nzme of Coammor) ansur-an=CompaayNoticy Numb'rr) kTxpi mdos Dart). (attar i:d i'.ioSJ beer if aeoca._y w indt Se icfocm+�oa pa•u66,iag to cu oo=rA=.*a) I am a sGIc pFopretor and bave no one wor-LiDg for me. ( I am.a home owner perfor=m; all the work myself. NOTE:pick be a*-rc tbA,%,azjc boasc='acrs u+bo aaploy pc.-aoot t,,aka tt rrsc sa=z .taU Cr rgait-wk ca a d+-W--Z or am tSOCC tll.-..6 tj=_--Ws ut w 1&UX bowooN'mcr rmj=or w thL pv c.:S VptKlCO3i.i tbC+C.G LT OCK C:--Uy OQG:tGd. to be -tployca u0e—the z m=p--. ca Act(GL.tI32xs t{5)1.=4*11csaoa bq a bomaow=rc:tie=•-a pa=nt=--Y e. tbt lega)et. of u-=;,loya under d'.Work e,Camgomstioa Act I vadcrm%ad tba a copy of tsw mtc may b,.rormYardnd to erg.Dcp.naooas orIpdatYJiat Aoaidam&OM"orLw-~d rat tb. ooze ra if csiaa gad th t L-i am to s cum leawr Cc uodc wain*23 A or)tQL 152 oaa lod to the Lzpamsioa of aimirsal pcoaltio ooait;69 of a.fix or up to S]X00.00 anejor orup to one ycer e,ad cNz1 pcoaWo in tSc form ora Stott Wok Order•.ad a fibs or S 1 Woo a day tpaica Qy- Far PCfmjt NUIDLI- - I•dap=-- Lot° f 'L Of Ltc=n-tt-f-IPrrmittrr ra SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sue or: Not Applicable ❑ Name of License Holder License Number ze a Address ^ Expiration Date Signature Telephone 9.Realstered Home Ilmorovernent Contra gl r: Not Applicable ❑ Company Name R6gistratio Nu ber 0 -517 Address Expir6tion 6ate Telephone_ 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 affidavitwill result in the denial of the issuance of the builoing permit. Signed Affidavit Attached Yes......, No...... ❑ 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 1083.5.1. 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 1711 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding [p] Other ) Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housina, complete the following: 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. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. 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 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 AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize ��C��L' Cf7 C{ re- to act on behalf, i II matters relative to work authorized by this building permit application. _ipy , pd Signature f Ownef IV Date ICl '1 / L as Owner/Authorized Agent here 6y declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed u der the pains and penal' s of pe:79' . Print Nam / 7 0 Signature of Owner/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 -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 Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW �- YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , 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: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �12 �b Street Sewer/Septic Availability MAR 2 R` 100 WaterMell Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit � l I��/ 19�, L2, Zone Overlay District �/ /' Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Addr Telephone Si nature 2.2 Authorized A ent: Name(P1 rint J' Current Mailing Address: "n 1�z' Signa re. Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 00 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 7,� 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number // This Section For Official Use Only y� 7 tN (G Building Permit Number:q7P`�D ' IO I Z- Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2006-1012 APPLICANT/CONTACT PERSON Andrew Church ADDRESS/PHONE 184 Spring St FLORENCE (413)586-0918 PROPERTY LOCATION 18 BATES ST MAP 25A PARCEL 143 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid uilding Permit Filled out wee Paid G Z Typeof Construction: Tear down and rebuild chimney New Construction Non Structural interior renovations Addition to Existing Accessory 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 PRESENTED: t/pproved 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 C�- 03 h,9 66 L I 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 i BP-2006-1012 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25A- 14A CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2006-1012 Project# JS-2006-1497 Est. Cost: $0.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Andrew Church Lot Size(sq. ft.): 5052.96 Owner: SULESKI ISABELLA R&DEBRA L SZPILA Zonin :URB Applicant. Andrew Church AT. 18 BATES ST Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON:312912006 0:00:00 TO PERFORM THE FOLLOWING WORK.-Tear down and rebuild chimney 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• Date Paid: Amount: Building $25.002592 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 18 BATES ST BP-2006-1012 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A- 143 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-1012 Proiect# JS-2006-1497 Est. Cost: $0.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Andrew Church Lot Size(sq. 1): 5052.96 Owner: SULESKI ISABELLA R&DEBRA L SZPILA Zoning:URB Applicant: Andrew Church AT. '413 BA T CS 3-1 Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON:312912006 0:00:00 TO PERFORM THE FOLLOWING WORK.-Tear down and rebuild chimney 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:pir y-S - 4 41 A% THIS PERMIT MAY BE REVOKED BY THE C Y OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Si nature: M�a�D FeeType• Date Paid: Amount: Building $25.002592 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo