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17B-013 (4) 0 61h) of Podilailipfoll Alas 6 1;(hnrc its DFPA.RTM1WF op Buiu)rNG INSPEG-FIONS 212 MaLiri Street * Municipal Building Northampton, Mass. 01060 WORICER'S COMPENSiMON INSURANCE AFFMAVIT with a principal place of business/residence at do hereby certify, under the p;-11IS and penalties oflp(�qmy, trim 1111 an empiover providing dIc fbllowI*M, W01-Ir"cl-'s comnmc,:_uwn covcla, ge, for my on tm j("h Coma my) (Lip f-zwn DaI^) 1 MII a sole proprietor, general contractor or homcowne-, (circle one) LId have hUtci t,fle Contractors listed below wlm have the follo�ti-,,ip, worker's co-L-n.pens-non pokies. of Contractor) (Insurance Companv-Polic, NumiK-,) Da[c) (Name Of Contractor) (Expiration Date) ,Name of Comnicio, (Imumrlc: Comp"111)•/Policy (E-Nplmuon Date) ('Nallic of Contractor) Co III p myfpol icy NuIIIIKI) (Expiration Date) (,.11,11 uidiucxlaj t!u<f to to nll am a sole pmpnetoi and have no one working for me am a home owner perF()rjI11n0(1 all the woiI rnyse.1f, N011-i plc_-sc be nvrrc that wIido hocw,,vTK" vbo w&mj=czxa,,murinuajoo ar repair-uric on&d-zl1mg of not xnxc 111to thrm w1ki in%%incb tax 1xnnro-wT r"idc:3 or oci tl.t cTouncb apputicnui tSacto&-t i)cx ccr-wrilly o0cokk-d to be 1v-'P1o)­5 under tte,vvtxl cis oDrr�C- licn Act(GI_152_T31(5)�afVtica.6on by a bomco�-,=for t 6cam or p(rmi,many-id—the legal O_Ab a of an cxvloyx under duo WcAe &conlpm ilcyn ACC I u.Acriland thxa a c'o'py of Chia"xt­cnt r y be forv,_jed to tbo DT> jn­nS of Amdca&Offioo of Lrauxnoa for Lb- -V-xf-,t vtrificmiioo and th!"f_-iltzm to secure cOvcTn ,un&-r section 25A of MOL 152 can 1,.d to tb-imposQiozi of—ind Pc slb- cOcMlaing of&fmc ofirp to S 1,500.00 mr-dIct uwp owncvd of up tom year End Civil PCDIILJC3 in d)c form of ft Slop Wori,order and I firr,of 5100.00 a&Y acne 1 UY For u- --Jy PCTTilit Number N I:I P4, Lot 4 Si),";Itilrc of 1,iami5c.c/Pcrniiitct. --iAve- SECTION 8-CONSTRUCTION SERVICES B.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9 PiAiter'ed HQmgfmnrovemenfiContrac Not Applicable ❑ Company Name Registration Number e,,rl Ste" s'-/S- - J Z Address Expiration Date / �Jor,-/ Telephone 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....- ❑ 1..= Home Owner Exemptioi 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 buildint;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 endows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: L)V! i ]( Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative G Renovating unfinished basement Yes No Plans Attached Roll l:, - Sheet 0 6a:If;N W house,anct=oraadditiorr�f""exi`stirr�" tio�isinv`"'`com lef ttiefofl'bwin'°-: 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 SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED 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. Signed under the pains and penalties of perjury. Print Name Date Signature of Owner/Agent 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 a —Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parkin 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: 2 ty f ' ampton ing tment 11 ain,k pet oom m r'00' North , pMA 41062 it ho �{ � 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 sectionito be compl3etp by off icq- ,k �r ,3p y �/�lGl!E' f' Map �. LOt l fi{t Zane Overlay.District Elm St Dis#rict CB'District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: &44 Name(Print) Current Mailing Address: Telephone - S:_- �,. v� Signature 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 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 = 0 + 2 + 3 +4 + 5) r© Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 384 BRIDGE RD BP-2001-0471 GIS#: COMMONWEALTH OF MASSACHUSETTS �I.ap:Block: 17B-013 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:windows replaced BUILDING PERMIT Permit# BP-2001-0471 Project# JS-2001-0802 Est.Cost: $650.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Ed Corbett Jr 116069 Lot Size(sg.ft.): 9408.96 Owner: LASTOWSKI PAULA M Zoning:RR Applicant. Ed Corbett Jr AT. 384 BRIDGE RD Applicant Address: Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTONMA01060 ISSUED ON:1113100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings inderground: 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 Sianature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 11/3/00 0:00:00 1050 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo L 384 BRIDGE RD BP-2001-0471 GIs#: COMMONWEALTH OF MASSACHUSETTS Map Block: 17B-013 CITY OF NORTHAMPTON Lot:-001 Permit: Build n Cate&W::windows=laced BUILDING PERMIT Permit# BP-2001-0471 Project# JS-2001-0842 Est.Cost:$650.00 Fee:$25.00 PERMISSION.IS HEREBY GRANTED TO. Const.Class: Contractor. License: Use Group: Ed Corbett Jr 116069 Lot Size(sa.ft.): 9408.96 Owner: LASTOWSKI PAULA M Zoning:Ratnlicant: Ed Corb.btt Jr AT: 384 BRIDGE RD Apph Ica ntAddress: Phone; Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTONMAO1060 ISSUED ON:1113100 0:00:00 To PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector 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: t1 K IV-/V .d6q THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of cc anc si nature: Fee Type• ReceiutNo• Date Paid: Check No: Amount Building 11/3/00 0:00:00 1050 $25.00 212 Maur Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo