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DEPARTVL-:N`r OP 13UII1D.r7'G INSPECI-IONS
212 Main Street * AJujjicipal Building
Northampton, Mass. 01060
WORICEIZ1,S COj,4TENSjknON [NSU-RA-NCE k , , AVI T
v,11ith a principal place of bUs1'UP-S&/FeSIdenc'c at
——------------
do hereby certify, under the p,--irLs and penalties of perjury, hat
I am ail employer providing the foIlo\viniz coverage for my
C111(flovcCS \vol�-Jlw on this 'oh.
(111sur2lic-
am a Sole proprietor, gcrtci-,ll contractor or hojjjco«-nc.- (circle one) and have hired
the contractors listcd below who have the f'OU,-.)VYU' p' workers C")E-]Dtnsaton pokes:
(INa-mc of conl T-zic-'01r) Oasurancc Compmy/liotic-, (E-xpij-,iuon Datc)
(N'amc of COL)-T"C-,Or) On-qir-ancc CoTjmaiv/PotIc-,, Nwijcrr) (—Expu-noon Date)
(Naive of coaLnlc-io;) (In�-U=cc cornpa11)/-Pokc:-'• (-ExpLmuon Date)
(Name of Conti-actor) --(Insurance: Compaiy/Poldicy (E\pLi-ancia Date)
to all
Ln a sole pi-opnctoi- and have no one wor!drig for me,
a-in a home owner perfo=' ,, all the work mysdf.
NOTE:please be AW-41-C d1z-'IAIO h'xr'cuwncn wtx)cmplcy mom to c3o rjzt•�,qcr v r^ oa cr rupw wo&-co L dl'eJL129 of
--(.r dL-11 Orc-0='d to wlincb LLc Scnnc.,0-TYCr rr-lid'n(X cxI th't UrOU13'j,appurtenirl tj)'='to arc m-,(&cn<mlly ocK-z:ckrcd Lo be
-IVIOY-urxt'r the Ac,(GLI52,z 1(5)�af-vtic3.6cm by a hoc co°A-=for a kcax 0(po-ru?-Y cll�x the
O-In-of an-=Ployx uudor d�' Wokc'-Coc�pcm.iion Act,
u-:crct�id diji a copy of this asLa—i o y be fcvcied to tbo D':T-,_oj of L_j_': j Ar d-&Of of ln�+z°`»for Lbn
cov"Et vcrlfi=iOc a-ld Lhat fA- L-"c W ta,d-&oction 25 A of N(Gl-152 can[.,A to Lb.=po-ti-of-m--11 P-il -
co-L54-L-tg of a 6DC of up to S 1.500-00 and/ff i:1{rnooriX11 of up to ore Yn,j&,-.d cj-'-d pc,,.I-jc,in d)c form of a s1cp Work Order a-'Id
rim a(S I DO.00 a d Y icsui�cc
Foe"I&7- �l Ux only
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Sir",WIFIC of I.iccii--,ccjjIcr-;mttcr-.
SECTION 8-CONSTRUCTION SERVICES
j 8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 Registered Home tm�ra 'eriienfi'Contractor �_, ,,. ...w r ,, , „# Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 ❑
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 buildiny, 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��cable3
New House ❑ Addition ❑ Replacement endows Alterations) ❑ Roofing
Or Doors
Accessory Bldg. ❑ DemolitionD New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:—LLV-5_YV//,}7.
iac-f— 0"1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet❑
6a:t lfNew-;house=.a�t� ar?aticli�ii�r� #o�zist�ri�, hoi'san.�:`cO�plet�'t1 � fiOEt®w�iri�:
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
I, 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
RON!111i 11;
,rs R
I, I.111// ~1 , 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..
/ (�" 'e,-n�—
Print Name '
Pa
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST ]BE COMPLETED, or PERMIT CAN BE
DENIED DUE To LACK OF MORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
V
Frontage
Setbacks Front
Side L: R:- L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bid;&paved
arking
#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:
Yt__. Ar^a YC f2*�A F�TL*pVL:L t� U•USeU 6t� E, k A'C K
am e0 a a �x 3 far3 > �y
City of Northampton � � �
F�
Building Department ors t Pe rrm �
212 Main Street
Room 100
ru��r(abrik� ,
Northampton, MA 01062 ``���"`�
p Tsro�'StricturJaS � � �us' `at6
hone 41 587 1240 Fax 41 7 '` r x
p F 3587.12 2 Pct/sit Pans ,,,x, �4"M ; ' i , Y
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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
Zone ' — – Overiay,Destrsct''
EIS St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1,Owner of Record:
Name(Pri t) Current Mailing Address:
Telephone " 7
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 =G + 2 + 3 +4 + 5) �' Check Number
This Section For Official Use Only
Building Permit Number: R-R3y Date issued:'
Signature:
Building Commissioner/inspector of Buildings Date
a
�w
F
4 STOWELL ST BP-2000-0994
GIS#: COMMONWEALTH OF MASSACHUSETTS
M :apBlock:I IC-026 CITY OF NORTHAMPTON
Lot:-001
Permit: BUildinQ
CA=ory:Loo ng BUILDIN G PERMIT
Permit# BP-2000-0994
Project#; JS-2000-1815
Est.Cost:-$, 775.00
Fee: 25.0 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Sites$.ft.): 8494.20 L9wner TIC PlG ELE M
' Zoaang:URA ..,. Apr't ;: Ed f orbett Jr
AT 4 STOWELL ST
AAnlicCWAAd'dress: Phone: Insurance:
4 ReedL Street (413 5) 86-5192
NORTHAM PTONMA01 060 ISSUED ON:5191010:00:00
TO PERFORM 7WE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & RUBBER
ROOF ON REAR DORMERS
POST THIS CARD SO ITIS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring B.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:.
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame;
Gas Fire Department Fireplace/Chimney:
Final: Smoke: Final• O�, S- 2mc0
THIS PERMIT MAX BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLATION F
ANY OF ITS RULES AND REGULATIONS.,,
Certificate of Occu2anc � signature:
Fee Type: Receipt No: bate Paid: Check No: Amount:
Building 5/9/00 0:00:00 3525 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo