12C-086 O O
of �'Tortllurliptoil
Q 6
Jai assnchntc(Is - —'
DEPARTNIE14T OP BUILDING INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
«'OMCER'S COQ TENSA- ON ENSURANCE AI MAVIT
(li cctlscx_/perrni ttcc)
\,,'ith a principal place of businesshe-sidence at.
(sar..•t/ ty(statc/zip)
do hereby certify, under Lhe pa_itl_S and penalties of perjury, ?hac
m an employer, providing the following %vorker's comoens: on coverage Cor my
efuployccs �vorng on tills job.
(IIlSUS?^(-- Corer-1ny) (Polio;Nu- r) (T;-pir�uor, Datc)
( } I ant z sole propr,etor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the foUoving worker's coo D msauon policies:
(Name of Con.--Ci0:) Orrsumncr- Company/PoUc-., NLLm' ,) Date)
(Name of Contractor) (bL5-wdncc Comoan},/Polk,• Nui-DCrr) (ExpTI.:Iion Date)
(Name of Cowamo,) (Laa anc: Compare}•/Polio•Numb:r) (Expirdod Datc)
(Name of Contractor) (Lnsuraacz— CompaBylpolicy Numbs) 1=.xpi-m6on DaLc)
(ea�u'h �ocaJ c'>l tf to c)G Ud;infocnuaoo pertainin£to all
( ) I am a sole propnetor and have no one worlmng for me.
( ) I am a home owner performing all the work myself.
NOTE:plc be ew a t 0—u{-jc bearo.tvcn wbo analay pcsiocs w Lz)c �cos- x c rruu«vra oa.G.<lL of
ant axxt tLr,t`nr_L=?u in ub;cb the bocnooHVCr raid,or oa lb- V-ouocis zppuricn_r`ib,- D LT o-x to be
employes uz-"—Lh't.o;i-d � _riov xx(GLI52,s l(S)� e bo co—a a fe c G a pstnrt try c dax t6c
1cgJ rtnnu of ea c=PIoyoc undrr d O Woc4clt CoaztwwAAi Ad
I undo itxad t1:+2 a copy of thi."ua oom my bo for—wn ied to tbo Dcpartmeui of 1"6 rJid AmdcarJ ofbi of trr�for the
oovmsc vcrifictioo n.'td that Liltsc w eoauc covci-n.sc under sou�on 2 5 A of tfoL I S2 na lad to the i-•-��2ioa of crimiail pea-+lrics
ooaairing of a floc of up LOS]}00.00 anNoc of up to one yc3 eud aril pen.fja in tx form of n slap Wak Order end a
fim Or!;I W.00 t day tpian car
For dc{�..-tnr�1 u.c oril y
Pcruu t N um bc-r
1 to
pre Lot
O �O
Signature of Liczr>_scr_1Pcrnut1cc —�
CTI[014' "-CONSTRUCTION SERv1c45
Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: AeM" --
License Number
1000 yak 3.o?- �%fpt.�.�,ar�r�a�. .t. ots z,-51- f/.2f/ R'
Address Expiration Date
Sigmup Telephone
Not Applicable ❑
Company Name Registration Number
Po,aa 3 o Z �• �.o�l...lr� , .�,�ss G��/2-�io
Address Expiration Date
Telephone �2'✓'raZ�lS
secindN;11 W}RKERS'COMPENSA?TIpN INSURANCE AFFIDAVIT"(M.G L.c.152,§ " i (S}
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 haws 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
.rw
i° applicgM
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:~Aj!ai eOldf -14umL
Alteration of existing edroom Yes Al'm~ y
g 4,- No Adding new bedroom Yes �No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a. Use of building : One Family y 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?
Type of construction
1. 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-01N ER�tItHORIZATION # C COMPLETED WHEN
ipyfiNERS: I OR CCNIRACt'OR APPLI� I'OR�BUILOIN4 PERM17
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 Ownerki Date
I, 44roj TLT �' , ,�L�G'rTl'C""" , as Owner/Authorized Agent
here y dec are 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.
rint Name
Signature Owner/Agent Date
✓� w p
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 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:
w c ?
City of Northampton
Building Department
212 Main Street
,Room 100
v Northampton, MA 01060
phone 413-58.7--1Z46 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1
SECTION''1-517E INFORMATIQN .
set
1.1 Property Address: �� r
:M Lot
We iitl� N
f
SEt ?ION 2-1 RtIiREIRTY OVIINERSHII'lpIJ1"H00 AGENT
2.1 Owner of Record:
Name( rint) Current Mailing Address: . �
Telephone
oignatu
2.2 Authorized Agent:
/OlO ,�OX 3d Z- L1-4o44G) ,4CW__g7Z,0
Name(Print) Current Mailing Address: 7—
�!3 � SZS= sz�G
Signature Telephone
S;EC7`l'O 3 E (MATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use,Onjy,
completed by ermit applicant
1. Building �, (a) Building Permit Fee
2. Electrical (b) Estimated Total host of
C d0 �Constrgctiori frr►rn.
3. Plumbing Building Permit Fee,
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 7 &P I .Cheqk,Number 37M7 I ._
Thal S 110" 'or C1►ffFCiaL'Us2.±Dnl
•Bu-ildin Perrriit Number: Rate Issued:
oignatu.e:
Building Comrnissionerllnspector of'Buildings Date
t s
File#BP-2009-0453
APPLICANT/CONTACT PERSON PROSPECT BUILDERS INC
ADDRESS/PHONE P O BOX 302 EAST LONGMEADOW (800)486-4976
PROPERTY LOCATION 20 RICK DR
MAP 12C PARCEL 086 001 ZONE URA(100)//RI/WSP
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:_FIRE RESTORATION,REPLACE 2 CEILING JOIST,INSULATION KITCHEN ONLY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 017699
3 sets of Plans 1 Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
__Z 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 Commission Permit DPW Storm Water Management
Demolition Delay
Zv/;" ;,
r.
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.
t j
' BP-2009-0453
GIs#: COMMONWEALTH OF MASSACHUSETTS
mom j" CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0453
Project# JS-2009-000610
Est.Cost: $7000.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PROSPECT BUILDERS INC 017699
Lot Size(sq. ft.): 10018.80 Owner: SMITH JANET C TRUSTEE
Zoning URA(100)//RI/WSP Applicant: PROSPECT BUILDERS INC
AT. 20 RICK DR
Applicant Address: Phone: Insurance:
P O BOX 302 (800) 486-4976 Workers
Compensation
EAST LONGMEADOWMA01028 ISSUED ON:1012712008 0:00:00
TO PERFORM THE FOLLOWING WORK:FIRE RESTORATION, REPLACE 2 CEILING
JOIST,INSULATION KITCHEN ONLY
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 10/27/2008 0:00:00 $55.0037149
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
BP-2009-0453
20 RICK DR
GIs COMMONWEALTH OF MASSACHUSETTS
Mal2:Block: 12C-086 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
ate or BUILDING PERMIT
C
Permit# BP-2009-0453
Project# JS-2009-000610
Est. Cost: $7000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GrOnp: PROSPECT BUILDERS INC 017699
Lot Size(sq. ft.): 10018.80 Owner: SMITH JANET C TRUSTEE
zoning URA(100)r/RI/WSP Applicant: PROSPECT BUILDERS INC
AT. 90 RICK DR
Applicant Address: — -- Phone: irsur urzcer
P O BOX 302 (800) 486-4976 Workers
Compensation
EAST LONGMEADOWMA01028 ISSUED oN:1012712008 a:ao:ao
TO PERFORM THE FOLLOWING WORK.FIRE RESTORATION, REPLACE 2 CEILING
JOIST,INSULATION KITCHEN ONLY
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Q Footings:
Rough: Rough:/��LO House# Foundation:
Drh,eway Final:
Final: Final:
Rough Frame: fJK 1012
Gas: Fire Department Fireplace/Chimney:
Rough: Oil:
Final: Smoke: FinaliV f f—( �.-OF A--
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. v
Certificate of Occupancy. Si nature:
Feel e: Date Paid: Amount:
Building 10/27/2008 0:00:00 $55.0037149
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo