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DEPARTMENT OP DUILDrNG INSPECT101JS —
212 Alain Street ' Municipal BuddinE
Northampton, Mass. 01060
WORKER'S COMPGNSA'MN INSURANCE AFIMAVIT
(li ccus:rJpcnni ttcc)
with a pi-mcipal place of business/r ncc at-
--- s� Cor f 14u — � 1Gftn 0;1101e =)(8)3
do hereby cer-tify, under tale pains and penalties of perjury, ?hat
( ) I un an employe: providing the followinf_ worker's ccmr)cnsa.lo;: cover-2.c Or Im,
etuplovccs on uhis)ob
(a=s oG Corgi r,Y) (Polio: N L�ccr) -- ;pir Uor, Disc)
( ) I am a sole prooncror, general contractor or homeowner (cucie oee) and h ve hired
the contractors hsted below who h2-%,e the follo%ving •,vor-leer's comnen-s-2110n -I)OkIes
(1`amc of CO !;;'.CiO") (ltlRlmncr, CoInDaTI '/POrIc'f
(Name of Conrnc,,or) OJISuFancc Comoan`•/Po1jct Nuz�crr) (��z r.ion Date)
(Name of Contractor) (I-nsurance Compan}/Pot:c)• Numb--r) ('.xpitling Date)
(Name of COMT?Cior) (Insurau� Com�,2ny/Pokcy Numtr:r) (i xj.,�r-anon Date)
(ana� 6 i Deal sad Iuc. :. r co n u afo uLion p zta:n rig to aL
( ) I arm a sole proprietor and have no one worming for me.
I am a home oNvJler perfonrning all the work myself.
NOTE:ply be.w is tJi ut o cMplay Pc Cul to 60 c-rr u Qfk m.d..tll_^of
ont—Ll—L7cr_ u n c; tx txrt»ouv t ra 61 or oa the VIDIJndr zPpurte t r t o e o-x Cc -Jj y ar:6�to Lie G
cnploycvs ux',-t!�c..tz{c>:-MP" Iim Act(GL1 apptiariao try a 600u0a1rr far c lip=a Permit rr_y c ids trc
Icgl't—*"of ca—rtoycc uOd—dro Wlild,(�a�ip A�("
I undcrz d the>Dopy of lhiz r�—Y bo fog--J-d a tba Dcl—,- t of Offioa of b uzocc for dx
oovmgc va-LGclioo-ad t1LI to scttrrc--'C rgc under 25 of MOL 132.Iced to tlx E^r itioa of cnmi"PCOAWa
ooa3uting of i Fmc of up to S 1X00.00.r Vex ralfriioa¢rcry o f up to oc year and a�1J pcmtuo 41 dx fexm of a Stop Work�a
fern o(SI00.00 a d-,y tgx=1 rn-
/ PcT ut Number
ac"S knatun ofLiarivc/1'cr Ii e
CTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
y .•__• Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone SECTION10-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 affidavit
will result in the denial of the issuance of the building permit.
gned 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 and c Zonin ws and State Massachusetts General Laws Annotated.
r'
Homeowner Signature
TIO S- D SCR TIQ OF`PROPOSED WO check all'a lica ie
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitionn New Signs [ ] Decks [ ] Siding[ ] Othe q
Brief Description of Proposed Work te� Xl'Sh' ' r tAOr d� v G�r vh tt)0`� r►n� c to
Alteration of existing bedroom Yes—,,X-No Adding new bedroom Yes X No Un GILQ�t1Q26(,
Attached Narrative ❑ Renovating unfinished basement Yes >No
Plans Attached Roll ❑ - SheetA
4- y a j '" ',
a. Use of building : One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms_
c. Is there a garage attached? no
L°SkQpe.Q
fmva 4
d. Proposed Square footage of now construction. 32- 5- Dimensions (o X M- + 7'ZX lf'r rr
e. Number of stories? Z
f. Method of heating? 0a 1&ced' et - Fireplaces or Woodstoves—,-� Number of each
g. Energy Conservation Compliance. 1*4 Mascheck Energy Compliance form attached?
Type of construction COft -eyQ rne-
i. Is construction within 100 ft. of wetlands? Yes ��No. Is construction within 100 yr. floodplain Yes_)r-No
j. Depth of basement or cellar floor below finished grade /O r,
k. Will building conform to the Building and Zoning regulations? )n Yes No .
I. Septic Tank City Sewer�K Private well City water Supply _
SECTION 7a-,OWNER AUTHORIZATION:-TO BE COMPLETED WHEN
OWNER$AGENT;OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
4W lC.!'YAQS , as Owner/Authorized Agent
hereby dec re that the statements and information on the foregoiare true an accurate, to the best of my
knowledg and belief.
ed under the pains and penalties of perjury.
A4,4 ff A e w Oy;,�
�rint Name � p
ignature of/owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
i
Lot Size ,) , Wo 4h Q,
Frontage + 'r
Setbacks Front 14'to FV CA, 2D`lb hausc,
Side L: S R:tS' L: R
Rear
Building Height Z�� �2 Stprie5)
Bld . Sqquare Footage to
14 137$
Open Space Footage 7701, %
(Lot area minus bldg&paved 7 111s.4. 0C ti"t lot
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T 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 `' 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:
RX
f Northampton
3 O ng Department
Main Street
DEPT OF BUILDING its; '
room 100
.,w. .hTfiFz�!°VAN ���I„ rEhatnpton, MA 01060
ph n'e 13.587-1240 Fax 413.587-1272
a�.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIO 1-SITE.INFORMATION
1.1 PropertyAddress:
This sectii�n tci Ise pteted°I�y office;
S Co V-444 - 1 t'V�,. Nlap �t Fnit
O ,mot Q w► y1 0 0`t® Zone Overlay�f >lt �--777
SECTION.2 PROPERTY OWNERSHIP/AUTHORIZI_D AGENT
2.1 Owner of Record:
me(Print) Current Mailing Address-
q.
r S_ . �Q
d Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
§E00114 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant_
Building �� 00 (a) Building'Permit Fee
7 2. Electrical 7 (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) F P111100 Check Number f�
This',Section:For Official Use Only;
mikuilding Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r ,r
File#BP-2000-1209
APPLICANT/CONTACT PERSON HAAS MATTHEW K&DEBORAH K
ADDRESS/PHONE 55 GRANT AVE (413)584-9303 Q
PROPERTY LOCATION 55 GRANT AVE
MAP 25C PARCEL 099 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: REBUILD EXISTING PORCH FLOOR/DECK SAME FOOTPRINT,PORCH ROOF
UNCHANGED
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 LLOWING 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 Committee
S zOO ZJ
Signature of Building Official Dat
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.
55 GRANT AVE BP-2000-1209
GIS#: COMMONWEALTH OF MASSACHUSETTS
a :Block:25C-099 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-1209
Project# JS-2000-2102
Est.Cost: $2411.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa. ft.): 8319.96 Owner: HAAS MATTHEW K&DEBORAH K
Zoning.URB Applicant. MATTHEW K & DEBORAH K
AT: 55 GRANT AVE
Applicant Address: Phone: Insurance:
55 GRANT AVE (413) 584-9303 ()
NORTHAMPTONMA01060 ISSUED ON.•715100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD EXISTING PORCH FLOOR/DECK
SAME FOOTPRINT, PORCH ROOF UNCHANGED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
nspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: 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 7/5/00 0:00:00 3982 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo