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17C-068 (6)
1 QrYT'L I Of �,Trrrfllaiii ltol,l a P Q �asewfllnrftt.• :r DEPARTMENT OF BUILDrNIC INSPECTIoNs 212 Alain Street ' Municipal Building Northampton, Mass. 01060 t4`ORI£EIt'S CONG)ENSATIO•N 'L iS-URA.NCE A • •- riVIT 'tx) r...._._... ....__._._. _ ._.._.,.__. { (i;ccDscJpertn,u "It.h a principal plate of businessfresidencc at: 12" iv S' (phone.-:) —�'-i (strticii}Istatcrrip) 'do hereby tenth ,. under thc.p?-=' and penalties of perjury., hat ( ) I am an employer providing the following`wort-cr's cornocnsr::ion cove.Esc for my etnplovccs %vorlang on this job: (Insurnc Commm- (Pone:Number) (a-piradoa Date) ( ) I am a sole proprietor, general contractor or hotneoivner(ci:cie one) and have hired the contractors listed below wbo have the following worker's compensation policies: (Name of Conumakot) (tasurant.:,.Comparry/P,oUcy Nfunz^c.) ("El4 ujon gate) _ (Name of COntraot (JS] av CAIDDaa}POtJ S Nude-.0 Extirzton Dre) (Name of Conuaaa,-) (bL%uan= CompanyRoGcy Numbci) (F-%piraoon Date) 'E. imdon Dale)., f (Name of Contractor) (Lnsuz-aa Comcany/Paiicy Number) t (aG.ar�addiLOC?I t'?aG,irnbaCa-1r to ia[1WIC taratma_tiaa pC'tainiag b.11 aoC%x4:3) . I am a We pfep et©r and bare no one working for me. ( ) I am..a home owner performing all Lbe work myself. NOTE:PI=F be awate them-bile homeowam wbo employ p=%aw to da %^^ ••Y- rsm G rgas work on a d.•ctL b of not able thra three tmrJ to wb;&the bawaawow rc"o of oa the Pp O&tpp=u^••'tb=-Cw tic oa CC=Z&o0ossd-od to be c iip�trader ebe—&&%o ,�aroa Ra{GLII 32ss 1(S)l apptiea,coa by.bomwww fa s 6c=c a Pesmit trzy c%'&%=the ,coal at+^,•of as-=Pl"aadw ttto Woake.C*GV w ;*a Ace. I uoderaaad dLA a aa'P10f th6 mtmaaest aa.y b.rorw.rdud t4%be Dap..meooa of tad•tTJiat A04d*A&OW MO of Lo"`"'°oa fof tb oov c r ctif tatioa amd tltu f iltae to:Dios,boverase trades 3=j-a 25 A or MOL 157 can 1vd b the imPoasioa 0(taitaia+t Pcasbi- ot a fine ar to S, 62Pr600me� up y=r tad civil pmaltio io eSc roam of a Sbp wmlE turd-cad• aoauzm3 up .}00.00 sadlor or to Doe o Goa 0(3100.00 a dap auras,M Faf&P"w-z-J use Owl Permit Ntlmbcr ignantrc df LioassccIPersnitert i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable D Name of License Holder. License Number Andrew Church 040943 Address Expiration Date 184 Spring St Florence Ma 01062 1/10/2008 Signatu;T �, , 586-0918 8.Realstered Home Improvement Contractor Not Applicable D Chimney Saver/Andrew Church 104480 Companv Name Rouistration Number Chimney Saver of Western Ma Address Telephone Expiration Date 184 Spring St Florence Ma 01062 586-0918 7/16/0' 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. Sinned Affidavit Attached Yes.......X No......D 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 Gerson 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 nerformed 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 awlicablei New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[E3] or ` Brief Description of Pro osed Work: '7 JAI r dh zuw la -4- �r Alteration of existing bedroom Yes_& No Adding new bedroom Yes ✓\ No 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. 1. 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, X' "Ie , btly 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. / (0 2Z Signatu of Owner Da fie i �C7lreyJ (J"LGl/' 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 per�'ury. Print Name Signature of Owner/Agent Da 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 © DONT KNOW ION YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT 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 O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , 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: E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r Department use only --°' t�ity of Northampton Status of Permit: -Bililding Department Curb Cut/Ddveway Permit -- - 242 Main Street Sewer/SepticAvailability .—Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 44 „p'87-1��40 Fax 413-587-1272 Plot/Site Plans Other Specify err 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 / Y5— Che,J r5 —/' Map Lot Unit y{rye e, Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �C i 6 khwn :1P I- X Nc) Clue�1n�fi Na a(Print) Current Mailing Address. Z�&a j ',)JA ,X—(413) 5522- 0-701 Teleptione Signature 2.2 Authorized Anent: Name;11�� 5-3-�e 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) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2006-1390 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Category: BUILDING PERMIT Permit# BP-2006-1390 Project# JS-2006-2059 Est. Cost: $4700.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Andrew Church 104480 Lot Size(sq.1): 27834.84 Owner: JEROME KATHLEEN F& Zoning:URB Applicant. Andrew Church AT. 145 CHESTNUT ST Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON.612212006 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY 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• Date Paid: Amount: Building 6/22/2006 0:00:00 $25.002636 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 145 CHESTNUT ST BP-2006-1390 G1S#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 17C-068 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit#_ BP-j,006-1390 ''006-2059 PERMISSION IS HEREBY GRANTED TO t .5; Contractor: License: Andrew Church 104480 4 • r.. �;..; i4.84 Owner: JEROME KATHLEEN F& . V Applicant: Andrew Church —. AI: 145 CHE i f NUT Phone: Insurance: (413) 586-0918 FL„RENCEMA01062 ISSUED ON.612212006 0:00:00 TO.PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY POST '.JIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Numbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: ](tough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 4A' 7-,T-,f4 44;�" THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGU,IFOXION Certificate of Occu an Si nature: FeeType: Date Paid: Amount: Building 6/22/2006 0:00:00 $25.002636 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Connnissioner-Anthony Patillo