28-051 (4) hT0 o1�
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i m ll£P/u2TMEN7 Ot' LUILE)MG INSPECTIONS
212 Alain Street ' Adunicipal Iluilding
Northampton, Mass. 01060
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i
w0RICER'S COMPENSATION INSURANCE AFFMAVIT
i �i c h .. �--� �!-s �J Iry .--•--.
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Nvith a principal place of buSmessJrc.sidenc;
d0 llercby CerdilI , U17C' 1" ?}1C p2U1S 2i7� pCil.":l i1 CS Oi �Cr)llly, illi:i
I a-m an employei pmvldin- tllc oilo%T..:n". :Uli:CrS 1011]nC:]S U017 GOVCI2`,C i^0' :I])'
employet's "VOr-k-ing on t ill)oF,-
C-7- 3 o Z G 70 3
(Ia,-.L=a Comp am,) uon Date)
O I an] a sole proomletor, 'general c- ti c or cr hon_eo'.-"-Jer (Cl cle one) ?mod l:a�.�e hirer
the contractors listC Q i° 0'�i
.. llr
(-NI ame of Co1)tr:c;or) N,um rr) Date)
llsl r.ce _::�/Pc.le
(Name of Coatraclor) (lrl 1 3I1C� (_D �O1;C: 1 117;?f%;) --\.: 0 Dal,--)
(Name of Contractor) (Inn:r-Lj?C- Come io t e-
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um tl Ja e,
(^.[L\Gl lia�JCY:11 cC:xt:..._.... '.o:_...�... ...'.�:�ufte;:r-_.-.... � _ei;�•:<:ro.r':,r
C I illll sole })1"Ul?T.'1C:Ui S:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: C 4,e�t or �y /S �"% 0? 73 / s Y
License Number /
2/5 /�6►lso.—, ��tnur j✓t5� lyd
/,z /` -5
Address Expiration Date
;�• ,�� �'— 58Y-77 0 0
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
/,�'? A'"'r //," •�,�� 5«�«t S 13 Z /-7 Z
Company Name Registration Number
Address Expiration Date
Telephone 58y" 770 0
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 affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
I IV
11. - 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 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 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 D /
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[O] Other[o]
Brief Description of Proposed/
Work:
Alteration of existing bedroom Yes_X No Adding new bedroom Yes No S��'"`�► .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, 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.,L /
10.9 S /a/ as Owner of the subject
property // /� ,/J
hereby authorize l r th h i �C �ti l74
to act on my behalf, in all matters elative to work authorized by this building permit application.
)<[qlaajd M / /zd/o S
gnature of ner I Date
I ,�i c 41-1 Ic �J y -� as Own uth
gen ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my
and belief.
Signed under the pains and penalties of perjury.
/9Li �57�
Print Name
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 0 DON'T KNOW Q YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0 NO 0
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
212 Main Street Sewer/Septic Availability.
Room 100 Water/Well 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
�oZy �y�n �o�
0/06 Z. Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Print) Current Mailing Address:
Telephone IS&C_ /.3 c)O
Si ature
2.2 Authorized Agent:
'e'C 44 1:3 7--'9 D.-T , e I
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building l ,r� (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=0 +2+3+4+5) o o- Check Number 60
This Section For Official Use Only
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0318
APPLICANT/CONTACT PERSON INHOME HANDYMAN SERVICES
ADDRESS/PHONE 137A DAMON RD NORTHAMPTON (413)584-7700
PROPERTY LOCATI b24'F,,yAN 1U
MAIL 28 PARCEL 051 001 ZONE SA,`
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Buildins Permit Filled out
Fee Paid
Typeof Construction: ADD NEW BATH TO EXISTING RENO BASEMENT 10/27/04 ADD ROOF OVER
PORCH&ADD 8 X 8 PLATFORM- 1/21/05 -RENO KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Buildiniz Plans Included:
Owner/Statement or License 073454
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 Commissio
L Lao
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.