17A-069 (4) LL
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DEPT OE B1111 DING MSPECTiONS -
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' d DEPARTMENT OP DUILDO\10 1NSPECriolds —'
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
`-VORICER'S CONITENSAT'ION MSUR CE A ,F AVIT
(li ccnscrJpcTmi(tcc)
V"Ith a pi-incipal place of business/residence at:
A: (Pnone:,
(scrt�t/ci ty/state/2a p)
do hereby cerdi under the pains and penalties of perjury•, `-hal
( ) I am an employer providing the following worker's COMM)sL non cove mle for illy
elupiovecs worming on this job
(Im=a=m Coo=Y) (Folic: NtL- b--T) -- (' :-p1r,tion Dare)
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the cootractoi-s listed below who have the following worker's ca)moen_'-adon policies:
(Nalvc oi-Coa! acto-1 (lr1'l!ra11C;^ (—Expialuon Datc)
(Name of Coatraclor) -- Gas-arancc Company/PoUcy Numn-2r) (Expiration Date)
(Name of Coan-wior) (Insurance Company PoUc)- Nurnbu) (Expiroon Date)
(N2-MC of Coatractor) (Iasurancz— Compzay/PoLicy Numixr) (Expitatio❑ Date),
(mach acf�tocal c'>cd ifuco _i wfo U-:'ioe rcrtniains to all
l-Ar I am a sole proprietor and have no one working for ale.
( ) I am,a home owner performing all the work myself.
NOTE:Pl - be nw"t $ '' Jc bcaxouam"bo caiploy periom w c rr� U.•orx oa,d..c11vz of
not Mort than ' tmtu in%`b c ttx 1>otnno� rtmdo«oa the U-o, tr appurten:m tbcc..o�- ooe Cc>e-_jly occnd cd to be
clnploycs ki tb- --. >—lioa Act(GL152,s31(5)�:;vGtatioo by a homoow=feu:bcx_x or permit r=y c-idcnoc the
IcIPJ ctaau of as c=zployx uodar d>o Worn &Compowatioa AoL
1 uodQStand that a copy of tbi.crags may bo f,-,,id to tbo pcpatmm¢of i.6ur jd Ao d&Ofy offioo of tfrs.rti000 for the
—ov ze veri cztioa aM tltet L•iju c to soa=eovert�-a tn�drs socxioa 25A of MOL 152 etn lctd to tJx imq=i6oa ofaimirw peo�W s
comist of a Goc of up to s 1,300.00 and/or im�i orup to ooc yrar UA Ci i1 pcnahia is dX form of n Slap Worst Order nod a
fits o(5100.00 i d_y t&unst me
For 6 p.
Pcrm trm Num b-r cs only —
il
4 NbP"" -- Lot
SiEnatir - of Li scrll'cnniucc e
SECT[ON'8-CONSTRUCI`ION SERVICES
J Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: /AEA 71ST'
License Number
Address Expiration'tatuf
Signature Telephone
EE
Not Applicable ❑
MIR
P.'-e
Company Name Registration dumber
Address Exp atio Date
Telephone
SEC' If N 1�-IAtORKERS,; MPENSATION NSURANCE AFFIDAVIT(M.G.L.c. 152,§2 C{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 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
N6
C 4 5- SC I POP ' WO c ec I a li able
New House ❑ Addition 17f Replacement Windows Alterations) R1 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: AC(IA w.? �►�7FAf!—kn,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet/
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?
Type of construction
5 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 _
SECT ON 7a QWNER2 AAU'1'f•IQRI!ATION'�'CQ.,89,COIV PLE'rED VIfHEIV
OWNt a4Gl NT CIIR C0INt1RA'CTCM APP1,IE FO �Itll�plNG'PERMl1"
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relativ o work authorize this building permit application.
ad4" If Signatur of Owner Date
as Owner/Authorized Agent
hereby declare tha a statemeAts and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under,th pains and penalties of perjury.
a e:
Name
e'
Signature o Ow r/Age 4Dte�-
4
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
azkin
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO V 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 k-'
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:
y of Northampton
I ilding Department
12 Main Street
1 2 Room 100
DEPT Of Dill 44 IN ECi1 rt ampton, MA 01060
NoRTHAMPT 7-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEP*bN 1.-SITE INFORMATION"
9d Thls t�fh .g, /3
1.1 Property Addre � - r �
wa
LA
S CTION 2 PROPERTY.OWNER SHIP/AUTHORIZED AGENT
2.1 Owner of Record:
T
Name(Print) Current Mailing Address:
hL4n-444 Telephone
aignatur
2.2 Authorized A ent:
Name(Prm Current Mailing Address:
Signature Telephone
SECT,jON 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be OfFidial Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total oSt.' f
Construction Irorri° 6 '
3. Plumbing Building Permit,Feo
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4+ 5) vfi0v• c7U Check Number
This Section For Official Use Only
Building°Permit`Numper: _ Date Issued:
Signature:
Building Commissioner/inspector of Buildings DafQ.
File#BP-2001-0260
APPLICANT/CONTACT PERSON Craig Marney
ADDRESS/PHONE P O Box 128 (413)586-5512
PROPERTY LOCATION 16 MOUNTAIN ST
MAP 17A PARCEL 069 ZONE URA
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: ADD BATHROOM IN 2ND FLR SOTRAGE AREA
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License 057159
3 sets of Plans/Plot Plan
TH�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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
q- 13 •®o
Signature of Build' fficial 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.
i
°�T 'p°T e r'
9 �' E �{lssaxclluaclla
DEPARTMENT OF BUILDIXG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
REQUEST FOR PERMISSION TO VIEW RECORDS
OR HAVE COPIES OF DOCUMENTS IIA.DE
*�PLEhSE KEEP THESE DOCUTAENTS IN CHR'01dOLOGICAL ORDER *'4,
DATE:
a-l9/0 f PAGE:
FILE ADDRESS : f
N A.I,i E:
—Loo, E� S Pt+�`I0 -p -- ADDRESS
PHONE
UNDER MASSACHUSETTS GENERAL LAWS WE F,7EVE THE SIGHT TO Iv7EF,T
THE ABOVE REQUEST WITHIN TEN ( 10 ) DAYS OF THE ABOVE LISTED
DATE.
BP-2001-0260
16 MOUNTAIN ST
16 #: COMMONWEALTH OF MASSACHUSETTS
GIS Map:Block: 17A-069 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
or renovations BUILDING PERMIT
Cate o :Non structural interior
Permit# BP-2001-0260
Project# JS-2001-0436
Est $Cost: $15000.00
Fee:Cost: PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const.Class: 0571 59
I Grom
se roup: Craig Marney
Lot g ft) 1 001 8.80 Owner: MORRELL CLYDE E&ARLENE A
Zoning:URA Applicant: Craig Marney
AT: 16 MOUNTAIN ST
Phone: Insurance:
Applicant Address:
P 0 Box 128 (413) 5 86-5 512
LEEDSMA01053 ISSUED ON.9115100 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD BATHROOM IN 2ND FLR SOTRAGE AREA
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Buildings
Inspector of Plumbing Inspector of Wiring D.P.W. p
Underground: Service: Meter:
Footings:
Rou h: House# Foundation:
Rough:dl�ll 71d1'1ras g �/ /s�Q�
a
Final: Final: Jy l�1 je d yAf� Rough Frame: 1- 07 o
G Fireplace/Chimney:
Gas Fire Department
Insulation:
Rough: Oil:
Final: Smoke:
Final: C�r �—5
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF *�
ITS RULES AND REGULATIONS.
Certificate of Occu anc Si nature:
Fee Type: Recei t No: Date Paid: Check No: Amount:
Building
9/15/00 0:00:00 2571 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo