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17A-236 (4) y U ' 'To 13F"�D��)t G r F -rvi C Er v.4N/ri Vi N 4 t is i' ;. I7 1.AvL am' r l � � �1'rlassatf�usrtfs DEPARTMENT OF BUILDD\TG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northwr►Pton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as i:is/her construction sups: :;'sor. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be,a one'or"twoamf -- 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 home owner." The building department for the City of Northampton w_ants any persons)who seek-to use the,home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and r',egulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings(before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection.:The building department requires these inspections before the work is concealed,failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) i will call to schedule aii required building inspections necessary for lire uuiluirlg pcliiiit issued-to nee Date Address of work location O4(i1lJ-lP�-O J'. F E LLZf�7 LTpt Pori Ijmlipfoil ! R �1L]f RCII RL[t Is• ` DEPARTMENT OP BUILDI,10 INSPECTION's 212 Main Street Kunicipal Building j Northampton, Macs. 01060 1 «'OR10ER'S CowfPENSA170N MSURA.NCE Al i (liccnscxllxrus�ttcc) %lath a principal place of businessfresidence at: - - j U LJV f>D �' / Pb C C. I (sn-t~t/ci ry/szatl=fb p) do hereby certify, under the.paint and penalties of pcdl j I am an employer providing the following lworkcr's comocns-:ior, coverage for Illy I elnplovees worng on this job: Ali- (Insur'uc C 0 0 m (Polio: ( ) I am a sole proprietor, general contractor or homeowner(c cie one) and hzve hired the conzractors listed below wbo have the foDo-,viog worker's comoen_tat3on pokiest i j (,1;=c OT ConEmcror) (InRranc Cornoan)-Pi .'�'umrcr) (r:?i,�non mate) 1 (Name of Contranor) (Insurance Comoaa-w?oljL�, \uCc_r) Dale) (Name of Coll cI6 ) (uI5 ranCZ C-OMr2M)-/POI1cy NUMb_:) (Esoirtien Dale) I (Name of Contractor ua pyy cr t - _ . i (aas� i�oc5l s'�ca.iroeccLL.^}w c�du�iafocaiioa petniaia�to.0 wa--_=,o n) -1 ( ) I am a sole-proprietor and have no one wort-ng for me. ( ) I am..a home owner performing all Lbe work myself. jNOT;.:pt=L c be-W-Lm t_*s_ Lbca,,c���+=ae wbo c=play p,z=- m eo cJD -. - c=—,c=,00 a rear•••oric on.d ill_ of ao(R)b(t�LL- ---xr l SR t b-Ch Lt,boo ^w lai&.<x oc IbC V,,,6 Zl� Ib,=. ,Ax Cc:> Dy oo^. ,6_—rd w be csxplo)— L--..aSrh - -,on An(GUI15Z=1(5)) =v-gLiaaw by.bomraaoa for_6c,- -cc panic ciy c,46 tbc legs!roc of es 4ioy,r under tb.WofScde CO.Po ..tiou Act i I t:ndct-sd tb->Dopy oI tbLi.mt®rat m:y lx(ors wded to Lbe( rtm ca¢of I�du r�J/c�dmxs OM of L=— o—(or Lbe cov= Zr v elf=oa sad UL-A&J%=t to xccxut'cO% r L�Lmdc==oa 25A cd 1.toL 152 m led m the imposiiioa of crimiast pemltic oo=zr-i%of L r=orup to s 13oo.00 rifor orup to Doc yrar sad civil pm.r,.is be focm o(_S%op Wort Ord-- ead flM of 5100.00 L d--y Lpiaa tD r. 7 `IF19 For 6cp.rLa+�sl u,c ont7 Permit Numbar i c3 P:-- .-Lot .' S Lf o Lic=-sccl c rnu ucc e J SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed S Construction Supervisor('fF }pervisor: Not Applicable [I p Name of License Holder:- nS- �1� � l'1 1 L—�"� 'J 1 L ( 7 P License Number g tJ DIi /1-t DU I= C yZ J �CZO J�1 r>- p,03 ?_A -AX' Address Expiration Date (4() _ lC-f- - -9 '� y Y- 1 Telephone 9egislere �omeImprQVerner> Gontracfor Not Applicable ❑ Company Name Registrat an-Num er —--- Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L- -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.......A No...... ❑ �n n + 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 a he liable for Person(c) Employees or injuries not resulting in Death)of the Massachusetts General Laws AiulOtatcu,ya::may.. r....._..,_, 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 r t SECTION 5 DESCRIPTION OF PROPOSED"WORK;(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[O] P'�`10DE1�i+b mF 40L—, fST F. 4_-7H. s (P ei2!^ Brief Description of Proposed d � � ' ,ZW- rzzew cs tTZ Work: /4— Alteration of existing bedroom Yes<No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes AC No Plans Attached Roll -Sheet® sa if IVe 14ou an ddii u O xist�n"? ,Oduslng s conmiete the a�otlbr xnq: 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 L 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 as Owner of the subject property hereby authorize th art on b half.in all ma relative t work authorized by this building permit application. Signat a of Owner k Date '--s S asA)wRer/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 L Signature of Owner/ g Date s Section 4. ZONING All Informatlbh 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 j Side _ L:! 3 R.i i U: R 3 Rear Building Height —_ Bldg. Square Footage % � Open Space Footage % — (Lot area minus bldg&paved parking). #of Parking Spaces Fill: volume,&Location 1 i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: i 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: T E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 r NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. a Department use tartly City of Northampton 4 µp,ti z Building Department b ewa srtt . � 212 Main Street tin 't Q Room 1.00 . Northampton; MA 01060 °r pht3Re 413-587-1240 Fax 413-587-1272i � r1e _ 1?ta APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1.-SITE INFORMATION Tits section toe cornteted by a#-tce ` 1.1 Property Address: 3 3 ti�m Dis3r ct CBD�stgct SECTION'2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ame (Printl Current Mailing Address: Telephone Signature 2.2 Authorized Agent: rQ/03y t L--X-t 1 W S(�( j l,c�U C(� t D 6 5- Ci f E' Name(115ri nt) Current Mailing Address: ` '( 3 r 3 ► ` � C � Sign tur Telephone SEG 3.-ESTIMATED`-ONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building '\ (a)'Building Permit Fee VU c� ' 2. Electrical i © (b)Estimated Total:Cost�of ° Construction from 6 3. Plumbing Buildln_q Permit Fee: 4. mecnanicai(HVAC') --- 5.Fire Protection 6. Total=0 +2+3+4+5) 3 6 b o Check Number This Section For Official':Use Only Date Building Permit Number Issued': Signature: r i BuildingiCommissioner/inspector of Buildings Date File#BP-2006-0893 APPLICANT/CONTACT PERSON John Zieminski ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014 PROPERTY LOCATION 77 LAKE ST MAP 17A PARCEL 236 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid ` T_ypeof Construction: REMODEL 1 ST FLR BATHROOM New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included• Owner/Statement or License 017889 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: 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 Commiss' 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. 77 BP-2006-0893 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON ;Block: 17�Ag-236 Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0893 Project# JS-2006-1372 Est.Cost: $13000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sq. ft.): 11761.20 Owner: MATHERS THOMAS M&KATHLEEN D Zoning:URB Applicant: John Zieminski AT. 77 LAKE ST Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON.31I512006 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL 1 ST FLR BATHROOM 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 3/15/2006 0:00:00 $65.005859 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo O�tlAMP�O m DEPARTMENT OF BUILDDKG INSPECTIONS �= INSPECTOR 212 Main Street • Municipal Building Ntuibamptan,MA 01060 . HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as-his/her-construction super•.i sor. The state defines"Homeowner"as,"Terson(s) who owns a varcel on which hetshe resides or intends to be;a oiu agr` J y 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 home owner." -- -The u g dep�nt or Me—OW of Ndwhampton wants any perSOU(S)-who-seek to _ . use the home owner exemption,to act as their o*n construction supervisor,to-be aware that by doing so You become responsible for compliance with state building codes and fegulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footinas(before backfiln, sonotube holes(before pour),a rou-h building inspection(before work is concealed) insulation inspection-Of repaired)and a final buildinz inspection.Me building department requires these inspections before the work is concealed,failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical,plumbing&gas)the homeowner will_be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued,.and that they get their required inspections.Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit Bate Address of work location .y o4•�itnMpTO ,!-- ��' � L1.I7 tIf �Ql"II�i�111�1f011 r _ r— P E �ta3sar�rtsetls' _ DEPARI-M ENT OP BUILDf\IG INSPECTIONS ' 212 Main Strect ' Manicipal- Building '°•, Xorthampton, Mass. 01060 'GRIa'R'S CONIOE�(SATIO-N 'L`ISUTCZ ?" A.�r1T` �--- CF (l;ccasciJpelmi ttoc) WlEh a prirhapal place of businesslresidence at: S. - } (sat`c/ciralstatc.�ap) do hereby certify, under the.pains and penalties of perJtuy, hu ( ) I am an employer providing the folio vint:t orker's comncaszboln Cove= for illy ; empioyces working on ties job: (Iasur�c Conr, y) (Policy Nt�r) {F-par-�ooa l7z�} ' ( ) I am a sole proprtctor, general contractor or homeovrner(c c:e one) and have hired the contractors fisted below rvbo have the following worker's compersadon.po!icies: (N=c Oi Con=c-too (In_curnnec Cornpa.r}Mobc{ (Ekilmuon Dnic) (Name of Coatractor) _ (lnssran="CompaaYMotier Number) (E.ivir tion Date) (Name of CoaMCtO*;) Qruuranc-- Cowpaoy/Potky Number) (Expiruos Date) (Name of Conaamor) am rance CotacwyNo4c Number) (E.xpiration Date) c,aav'f ocaJ e�aG.iteooc:a_-y so include iarW=.ion pentad n,a.ir (WI.am-'a sole pf0prietor and time no one working for me. ( ) I am..a home owner performing all t_be work myself. NOTE:plorc be twarc tat wb k beam*wvcs who employ peso=to do ee===-=roe a repair writ of a d.,rJLg of toe morn sh a t!ve=,in wbicis the bomoawncr rv+do or oo the pvuD6 spportea.a}bero Lys not Cx.=ay ooc:k%=od w be eitployes 4, the me s C2=*cc....iop Act t6Lk 52•s 1(S)3,_pplictdon by a bonito ver for a Gc=e«permit cr c%-;d==the legal et.w.,gran e,sley.r uodsr dw Wocltar'a Compaos.tion A.,- 1 +nd tba a copy of thi.=m=oor m.y b.f«x.rd.d b tb.D epanmma of U&"Did Aoeid�OQw.of txe acts ror dr oovcnpe reirsC:tiW am thrt L-=to ianrr e'Caucrago wad--soaion 25A of MOL 112 cat lead to the i cf cr6ital pcmdti's oom+:i:6 of a fine oCup to S l•300.00.odfor i=rr6cex=c:=orup to am yr_r rued civil pmaF.iea;O 6 farm ora Stop Wwk Order and &a C(SIO0.00 a day apica me ' P n Nnmlx•T i M Y - SECTION 8-CONSTRUCTION-SERVICES 8.1 Licensed Construction Supervisor. Not Applicable E3 Name of License Holder • License Number Address Expiration Date Signature Telephone SRe' ster t-1=56 i eat o Not Applicable 0 Company Name Registration' u Address Expiration Date Telephone SECTION 10-WORKERS'COINIPENSAT.fON`1NStlltkoo400��`(61tCr.1~6-Jtt�}) . 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 it =Signed 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 1083.5.1. 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 O1Ecial&g he/she sball be responsible for all such work perforated 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 on liable for person(s) you hire to perform work for you udder 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 t • r. SECTION 5-DESCRIPTION OF PROPOSED W.ORK(check°alLapplicable) New House [] Addition ❑:. Replacement Windows Alteration(s) ❑ Roofing Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other(E J Brief Description of Proposed Work: _A 9'i j 1 Y �Q— } �1n'`�l`\� (i i��-f t c�.�Q 'i r.�✓4<t C_i Alteration of existing bedroom Yes No Adding new bedroom Yes ,J Attached Narrative Renovating unfinished basement Ye.c s N Plans Attached Roll -Sheet 6aP074'W1OCt54SFT� @G �dID�sxi [rti$istlithOlTiiJ1Vi[lt,]: a. via of bUi:.ding:One Fami 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. 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. I. Septic Tank City Sewer Private well City water Supply SEC.•FION 7a-OWNERAUT- HORIZATION T�BE CO90"L F-MYW IEN - OWNERS AGI�ITOitOCiLRAGTOa1PPElES f®ktBbiC�iFGE'ERMt'f i, &Y c)- ' as Owner of the subject property hereby authorize / G/'►2 C7 77,E L. t act on behalf,in all matters re tive to work authorized by this building permit application. Ca 2—C '- Signature of Owner Date as Owner/Authorized Agent hereby declare that tMe 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. i / r m a-7--14 Print Name �- 6 6 Sign re of Owned .Date Section 4. ZONING All Informatioh Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be fined in by Building Department Lot Size i t -Frontage Setbacks Front j { Side L:' ; R:` i L_, 1 Ri s u Rear - Building Height —` ^ F ' Bldg.Square Footage j E % ; Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces Fill: (volume&Location) i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW Q YES 0 IF YES, date issued:! ' IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW O YES 0 IF YES: enter Book ( Page! and/or Document#I ! B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q ,. NO Q i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. a 1► City of Northampton ` Building Department 212 Main Street Room 100 r _ . Northampton; MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION'1 SftE INFORMATION 1.1 Property Address: _ a TF 7. us section tabs corn feC b�ce e J( app tot UAiL IUAD � �� otierlay`Clrs�rrct z �EIrt�St;Distract �• s.17rstnlct SECTiON`2-PROPERTY OWNERSHIP/AUTHORIZED AGENT.. 2.1 Owner of Record: I ame Prin Current Mailing Address: Telephone Signature 2.2 Authorized Agent: / ,n v --it_ J , L v C 20 b ov' 1 f� L- =0 S, Z 0fv. 3 / Na rint) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATEE-CONSTRUCTION.:COSTS Item- Estimated Cost(Dollars)to be Official Use Only completed by unit applicant 1. Building A/ 170 (a).Bnilding Permit Fee 2. Electrical (bYEstimatedTotaI Cost of ConstrijcUori from 6 3. Plumbing BuildingPermftFee= 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) -Check Number 7?iis`Sect�bii Eoc E>t€fidat.Use On Date; Building Permit Number Issued: Signature: r Budding Commissi nedlnspector of Buildings Date BP-2006-0893 77 LAKE ST COMMONWEALTH OF MASSACHUSETTS CIS#: CITY OF NORTHAMPTON Man:Block: 17A-236 Lot: -001 Permit• BUIICIInq BUILDING PERMIT Category: Permit# BP-2006-0893 Project it JS-2006-1372 Est.Cost: 13000.00 Fee:$65 AO PERMISSION/.S HEREBY GRANTED TO: Contractor: License: Const_- _-Class_ 017889 use Group: John Zieminski Lot Size(sq ft.): 11 761.2.0 Owner: MATHERS THOMAS M&KATHLEEN Q Loning URB Applicant: John Zieminski AT: 77 I-AKE �T --. - - � ts'c.•_.�;�� . Applicant Address_ Phone:. 3) 247-9014_ Workers 8 WOODRIDGE CIRC — Compensation HATFIELDMA01038 ISSUED ON:311512006 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL 1ST FLR BATHROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector Inspector of Plumbing inspector of Wiring D.P.W. Meter: Service: Underground: Footings: 12 l Rough-2 I- 4 Zou g h31,20100 R�'House# Foundation: .,3Drivewa),Final: p 0�-5-� 1Y 1 Fin-d: Final:�- � Rough Frame:0 K 3' Fire Deuartment Fireplace/Chimne}': Gas: insulation: -�r_:a�!• Oil: Final: 0K_ 0ylbt;�66 La uc`s Final: Smoke: THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON V10,LATION OF ANY OF ITS RULES AND REGULATIONS. si-nature: Certificate of Occupant — - -- —'— mt_ e' Date Paid: Aoun Feely Building 3/15/2006 0:00:00 $65.005859 212 Maui Street,Phone(413)587-1240,Fax: (413)587-1272 Building Couinlissioner-Anthc uy Patillo