25C-048 (4) �twr�
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DEPARTMENT OP DUILDFXG INSPECTIONS —
212 Main Street ' ASunicipal Building
Northampton, Mass. 01060
W O M,C R'S CO MT EN S A'I'I O N CN S URA_N CE AFFM A VIT
Qi c�.nscrJpermi tt cc)
\).,ith a principal place of business/residence at:
/G���_yi- S _�cl� iF�, /`�- e�irrG�(l hone;')
(mom/6ty/s 2ir-In p) ---
do hereby certify, under the pains and penalties of perJury, that
( ) I am an employer providing the following workers conlpensZLIon cove;2ge for Ind'
employees \vol-tDng on this job
(In=a=- n.) -- — (Pclic:ivumirr) ---- (T. pirtion Daie)
( ) I am a sole proprietor, general contractor or homeowner (ci:cie one) and have hired
the contractors listed below who have the follo��*ng worl;er's conin(msadon policies:
(Name of Con!:acrD-) (1nsuranczz CompanyiPGUC,-NtlIIL^ci) Darc)
(Name of COnITaclor) (Insuanc;, ComDanwPo!ic), Nt mt-2 ) (Expirauon Date)
(Name of Con.tractor) (Lasurancz Compan)-Roucy Number) (-ENpimaon Date)
(Name of Contractor) (Insur mc-- Compauy/Pobcy Number) (Expitauon Date)
(anach addi;ioaal ci_ixct if noarzin•w mdudc inforrv_'ioa pcztaiu:ng to a oo=nC_O:. )
( ) I am a sole proprietor and have no one wor-Lang for me.
am a home owner performing all the work myself.
NOTE::plcsc be awam thzt wlrJo bomcowncra wbo cmplay pcwm w do mxmtca•^?coaszl c oo Cs i-cpair woric ou a d.chin&of
not Mom th=thrOo umb III whleh the boa'ioownet r=d=oe oa the Uvjxid3 Ippllncwit tb=vLD LT riot gcoa'ally o:,=dered to be
employes u the wad is ocmpc=&riion Act(GL152ss 1(5)�appdcr bon by a bomeow=for t ticmn c cc permit may nidmcc the
Iegil etaau of an amployec uoder dio Workcea C,ompeasai ADL
I undcsiaad that x copy of thin cul.cmxi may be fofwnrdnd to tbo Dcpartmcot of ln�al A.6--ty Offioc of Irniuinoo for the
A� coverage vaificiuoo and that Uurc to caauc cova-&g under scaion 25A of MGL 152 nn Imd to the impoiiiioa of cr= aW cs
ooasiv-ing of a Gne of up to S 1,300.00 arwor isrr{n isooma of up to ooc ymr end Civil pmcltio io the form of a Stop Work Order Lod a
Gm 0(:s 100.00 a day tg&iml mc-
Fofn „c Daly
Permit Number
�...✓/,.. -... .,,...��_ m1pn Lot rt
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SignahttrcctsfLiaa7scrlPccmicta -���
ECTION 8-CONSTRUCTION SERVICES
_I
Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§250(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.
,04Fkigned 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 buildiniz 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 State of Massachusetts General Laws Annotated.
V--Homeowner Signature
r .
T P I YY c all a lic le
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other VT- 1
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❑
'A At jam
D
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: 2 Number of Bathrooms
c. Is there a garage attached? X___0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
�91- Energy Conservation Compliance. Mascheck Energy Compliance form attached?
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 COMPLE=TED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
igned under the pains and penalties..of-perjury.
t Name
Signature of Owner/Agent Date
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 %
(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 DON'T KNOWS 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:
f
Ulty 6orthampton
g Department
APR 2 B Main Street
-�- Room 100
°�?Nnrthampton, MA 01060
phone 413 587-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
This se+c�n t?Pcirnple#ed by office
Map.
I>rI►n 5'�C'l�strt'ct ,,.�...'.�'' Df s#rY�� �.��t,. .<.,....�.
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame(Print) _�- Current Mailing Address:
/ Telephone
Signs ure
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
com feted by ermit applicant
Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =G + 2 + 3 +4+ 5) 3 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2000-0951
APPLICANT/CONTACT PERSON HARPER MALCOLM
ADDRESS/PHONE 224 NORTH ST (413)586-3223 Q
PROPERTY LOCATION 224 NORTH ST
MAP 25C PARCEL 048 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 / _
Typeof Construction: REMOVE&DISPOSE OF ASBESTOS SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessojy Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Conservatio ission Permit from CB Architecture Co ittee
loo d
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.
224 NORTH ST BP-2000-0951
GIS#: COMMONWEALTH OF MASSACHUSETTS
,00*'1 ask: 25C-048 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-0951
Project# JS-2000-1743
Est. Cost: $30.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sg.ft.): 7579.44 Owner: HARPER MALCOLM
Zoning: URB Applicant: HARPER MALCOLM
AT: 224 NORTH ST
Applicant Address: Phone: Insurance:
224 NORTH ST (413) 586-3223 (�
NORTHAMPTONMA01060 ISSUED ON:512100 0:00:00
TO PERFORM THE FOLLOWING WORK.REMOVE & DISPOSE OF ASBESTOS SIDING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
,A*^,
Jnderground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/2/00 0:00:00 1331 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo