25C-099 (6) Crztlr of Nazt4ampt>an z
� � �lassac!liisetts
DEPARTMENT OF BUILDIJXG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
r'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc., sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
(!iiftj x1 ��t�-tlJ�tltt�fntt
� 6 ��aSSACllti6C1J1 � —
pry- -
^� DEPT-2TMEN-r OF BUILDI1�G INSPECTIONS
212 Drain Strcet ' Municipal Building
2,'orthampton, Mass. 01060
WOM ER'S COMTENSAUON INSURANCE AFFIDAVIT
1
v,,Ith a principal place of busir�ess/re2s dcncc
-- ---- --.—.--�Thonc
do hereby certil;,. tlnC cr the paid$ and I)C:1121t1eS Oi r)p ury, 'tha":
I am an employer pFovidirl- the follO'wim; '•':Cf :CIS comnellsoLlon GOvera'vC for my
employces worldrig on this job:
- (Ins.IZ'anG: CACi�m') �Glic:Nt>_"rltxr) --- (-r�.p;ntion Date) ':
l j I am a sole prop;letor, gtneral 1?oone0;vner ;cl cle one) and tlave tvrecl
the contractors tisted bei0w ,tc) i? the iOI�C...^r +vO1 K?�S COt::1peIlS2liOr1 -,"K.cS:
(Name of Co iLmctor) (E-x- :+. on, Datc)
(Name of Contrcior) 01-Lgummce 'rcr) (l x r-Iiion Date)
(Name of Contractor) Dat',-
- (Name of Contractor) — - (ILLS rallc� Comp i ,,1i'olicy Numb.-r) (E;:pi lion Dare)
L I ?III a home Cw?1Cr 'tiCir:C;"i?lII " al i ii: �ll.
N0"11--.:plcusc be nu•a:c that--vltilc r.-play;r. to;. incc z:._n wm cr:;a r ••;;c s�.cl!i ;c.
not UKcc than throo uniu in ut Ctl he k v.v-rc:'-,ut«;`: zn•_r cr_r1 LhcGc a-r rr.t :o t
cnIpfoyc3 utx;cr ihr wca: s cc z• irn i S ((>t.I52�a?(Si;,ai:;iia.'io:Iry a houicom]cr`or a l cw a
legal rtatut of an loyer under tLc Workcli
I
I undc--stwd dax:a copy of th:j ctzt--: rvy bo fot—,vdo-;l to tI»[Y-tiartn—d of Iru+ trid Ax6"�tj Ct moo of for tim '
covcrcgc vaifiic lioo and that f_iltuc to r uc coti r,ur3::colic.25A of MOM 152 can lc--d to[Ix inlpositia of cr ir_1 pct aL:u
comisting of a rm,of up to S 1.500.0.0 mr-r&,cx ir:ar. .rte;;!of]:p to rr,.}-c er.j civil xzutl u n dr fc nn c•f a S!c+' '+i'-Ch%=zrd
f ra of 5100.00 a dty
.. / For ci3:uvmta7 UPC crlty
I°Ll�/i ty f VLCIV ll _ tii / n ,O t
I
i
S�Ct10. GONS7RUCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
R;NR—e-r e e om ma ouetn'en ontractor= Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIO�f�120 WORKERS' COMPENSATION 1NSl7RANC'E 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)famines
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-vear 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 buildine 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 fe;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 ocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
g ure
SECS 0 �S RT O��PROPOSEDNORroucneck,4 fl a lacale
r
New House ❑ Addition ❑ Replacement Windows Alteration(s)� Roofing
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:Peoyahi'tA fhyCWit yuviw !o"QGfJi~Pauyit7r Gffirertt k_��PSi r0ow?
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative❑ Renovating unfinished basement Yes No eo porch.
Plans Attached Rolf Sheet 0 /
a fide "o° ea o Mc1'i#onto:exisinghh. uoinx 'om1e"eh efolilowt
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. 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
SEC I( N 7 d R AUT}�ORIZAT.[QN TO l3E COMPLETED WHEN
OWNEfS�GE T ORCON7RACTORAPPLIES FOR BUILDING PERMIT
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
i 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.
i
Print Name
4
Signatur o Owner gent Date
i
I
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
f
Lot Size
i
Frontage
Setbacks Front
Side L: R: L: R
Rear
i
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 DONT 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 DONT 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
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 4 3-5$742
r
APPLICATION TO CONSTRUCT,ALT EPAI Wfi0iDR O SH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE fiNFORNIATION c}
'Thsectw>txabe
pump teted boffice
1.1 Proaerty.Address: j
n
c M � � u
✓7-61�?t 6� ZOB b e1laY DlStl3Ct '
P 'y
?s�t[rf,�'S�D�Strrct .�".:'` •,as�� ?f4B''Q�sfr�i��� '�
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SECTION 2.-PROPERTY 011VNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
ZI/
Lct-tMrL111 A• CS
Name rint) � Current Man Addre
f( �
) S ' 9 30
�-Ze
Telephone
ignature
2.2 Authorized Agent:
Name(Pri nt) Current Mailing Address:
Signatu 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
2. Electrical - (b)Estimated_Totaf Cost of
Construction from 6`-
3. Plumbing y `S— �j � Building Permit Fee
4. Mechanical (HVAC) �C2,
5. Fire Protection
6. Total = (1 + 2 +3 +4 +5) "Check Number
This Section"For Offldat Use,Ont
Building Permit Number: Date Issued:
i
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1339
APPLICANT/CONTACT PERSON HAAS MATTHEW K&DEBORAH K
ADDRESS/PHONE 55 GRANT AVE NORTHAMPTON (413)584-9303 Q
PROPERTY LOCATION 55 GRANT AVE
MAP 25C PARCEL 099 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Bu Permit Filled out
Fee Paid
Typeof Construction: RENOVATE KITCHEN BATH GUEST RM,LMUDROOM&ENTRY PORCH
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
INFO ATION 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 Pemlit 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 C ssion
Z 2200
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.
55 GRANT AVE BP-2004-1339
GIS#: COMMONWEALTH OF MASSACHUSETTS
M :BWk:25C-099 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: BuiU ng DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1339
Project# ]S-2004-2015
Est.Cost: $60000.00
Fee: $254.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 8319.96 Owner: HAAS MATTHEW K&DEBORAH K
Zoning URB Applicant: HAAS MATTHEW K & DEBORAH K
AT: 55 GRANT AVE
Applicant Address: Phone: Insurance:
55 GRANT AVE (413) 584-9303 (�
NORTHAMPTONMA01060 ISSUED ON:712104 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN,BATH,GUEST
RM,LMUDROOM & ENTRY PORCH
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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 7/2/04 0:00:00 263 $254.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
r..Gzfy of Xarthaniptan z
� � 1j11assxchicsrfts
DEPARTMENT OF BUILDINIG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Norfluunpton, MA 01060 ,
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups:•,-"ssor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two famII _
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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and r'.egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection(if required) and a final building inspection.,The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, _/�/�r/,f�(�.Q,�v understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date /
Address of work
location �"s' �rzt wf AVe,
r
�o Gc3 r,Oy
Gi/r
R E ft of �nrf�ii311t�ltDl.l _ —
A �tc3 tat chntrlIt, - -
4 DEPARTMENT OP BUILDr)\,C INSPECT101.'S
212 Train Strcet ' Municipal Building
?Northampton, Nass. 01060
W R ICI R'S C 0,NIT Z t S A-n O N LN S UIZA-N CE A FTTD A '1-l'
I
1 I,
i
01 ccvsxJpermi acc)
%Vith a principal place of businesslresidence at: - ------ -
(phone=')
(sn-G.t irr/sZatr_rzi P)
do hereby certify, under the.pp_int 2nd pen21ties of perjury, h i
( ) I am an employer providing the following!worker's colnDcn$cJo, cove age for InN-
elnplovecs worlong on this job:
II
Q SU-T mac coMrz--M,) (Polio:NU-Mir_r) (r:pirtior.D2i--)
O I am a sole prooretor, general contractor or homeowner(ci cie one) and have hired
the contractors lister+ below wilo have the follo%vino worker's c000ensadon policies:
I
("Na c of Con- .nci0") (InRlranc;: Company/PobCi NuII1
I �
y -
(Name of Concaaor) (Instu-ancc Compan}/Polic- N=Lc r) (Lxou Lion Date)
(Name of Comraclol) (Insuraac: Comte)-/Poucl (Expiration Daic)
f
(Name of Contractor) (Instuan Como
any/PoLicy Numkr) (Expird6oa Datc).
(ntI�Gh:d'',i�ocar�cct,if acccu:y to c�dv�•iaforma_-ioa pcz-tn,iaia.s to.17 oo2rso�) -
{ ) I am'a sole proprietor and bave no one working for me.
Yom} I am.a home olvner performing all the tivork myself.
�(
NOTE:plc=-%t be ncrNz tlu ,t to bemrnwxra..6o carploy pctow in cla r• ,, -tsoo c t au-OrX on t d-. U,--y of
ant mocc the tr rtx-J in u�i�the bomoocwcr raido a oa the[Sov1 s zppurtcn.a tbcrr t c DcK ca=-.ny ocrrd=cd to be
rmpioycs-y'' the c=--? - oa Aa(GUI 52,=I(5)� zppticn.6=by n boa=%ma fcr a 6ccr.or pc ik r=y c%-id=-tl:e
Ic-PI ctanac of na ex?loyec under dto W-k-ec Coaapom,tioa Arm
I unda:z..ad dul a copy of thi. ca y be foe-+.urdnd to the Dege,tmcoe of IndacKrieJ Acedeaj Office of Ir.+—ooe for the
cova-a.se`c+aireuoa mad that f_=r to Lo=m eovn-b&,Undcr se ioa 25A of MOL 152 eta Iad to the i=posi ioa of ei-:a pcn46a
oo isizz of a riot orup to s 1}oo.00 nrd/or i mpsiyoamc=of up to ooc y=r sod a%il pmnhao is t`ac form of a Stop Work Ordcr nod a
G=of SID0.00,dty�puatt me
For scy.rtai.}►u.e orrty
Pcrmit Numtxs
1,42p: Lot rt
Sipnaturc of Lic=zcc/PcMIiucc !6Ee ^-
SECTION 8-`CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature - Telephone
- - Not Applicable ❑
9.,,Ffeoa;'s"' "ere�om� a�verrtecorrC o
Company Name
Registration Num er -"_-- -"-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION"INSURANCE AFFIDAVIT(MG.L.c.152-f 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 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 an ocal Zonin aws an fate of Massachusetts General Laws Annotated.
Homeowner Signature
r
f
SECTION 5--DESCRIPTION OF,PROPOSED WORK(check,alFapplicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing El Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks (0 Siding[0] Other[d]
Brief Description of Proposed
Work: 'AAC 1 12Li,, 't l",
Alteration of existing bedroom Yes V No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes of No
Plans Attached Roll -Sheet
tia [:Nevi= 017enf>�SkdC{ttLOqt 7aXiStiilQ (IISiFIq.cOrtptetti�e fttor �ng:
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 BUILDtNG..PERMIT 11
l 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
1, i�t y asOwner/Authorized
Agent hereby declare that the statemerfts 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
Signature of Owner/Agent Date
Section 4. ZONING All Informati6h 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 I fl
Setbacks Front l
Side L:= R: L: R:i
Rear
Building Height I
Bldg.Square Footage
Open Space Footage -- %
(Lot area minus bldg&paved
parking)
{
#of Parking Spaces
Fill:
i
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:!,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page' ( and/or Document# I
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading e3cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
---; Nortf ampton
� B I i 9 Department
1 1�� 1 ain Street
om 100
on; MA 01060
phone 413- 7-1 0 Fax 413-587-1272
APLAI'ION P
,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE-INFORMATION
1.1 Property Address: x Thtstsect�on to be compfet<ed by office
0 vc, Ma m., r Uaatt
�•Y-W.
i
EIm St Distract CB B�stF?ct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
'l 1'' ct { ZIPS r at���_�T 'e
Name(Print) Current Mailing Address:
hone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3ESTIMATED�CONSTRUCTION.COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. 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=(1 +2+3+4+5) Check Number
Thin Section For Official`U'se Only
Date
"Building Permit Number" Issued:
Signature: '
i
Building Commissioner/Inspector of Buildings. Date
File#BP-2004-1339
APPLICANT/CONTACT PERSON HAAS MATTHEW K&DEBORAH K
ADDRESS/PHONE 55 GRANT AVE NORTHAMPTON (413)584-9303 Q
PROPERTY LOCATION 55 GRANT AVE
MAP 25C PARCEL 099 001 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
Typeo ion: RENOVATE KITCHEN BATH GUEST RM MUDROOM&ENTRY PORCH
THROOM gXMIL
ion
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
INFO ATION 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 Commis-'
Signature of BuilTing 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.
55 GRANT AVE - BP-2004-1339
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:25C-099 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1339
Project# JS-2004-2015
Est. Cost: $60000.00
Fee: $254.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8319.96 Owner: HAAS MATTHEW K&DEBORAH K
Zoning:URB Applicant: HAAS MATTHEW K & DEBORAH K
AT. 55 GRANT AVE
Applicant Address: Phone: Insurance:
55 GRANT AVE (413) 584-9303 O
NORTHAMPTONMA01060 ISSUED ON.712104 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN,BATH,GUEST RM,MUDROOM
& ENTRY PORCH, ATTIC BATHROOM
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 7/2/04 0:00:00 263 $254.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo