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DEPhRTMENT OP DU1f1)ING ,NSPECIIMI'S
212 Main Street ' Municipal D-Id-!f;
Nor LhampLori, Mass. 01060
VTIMIICEWS CONT_PLNSATION Ci�'S�JR,INCF 11I'LI��l\rl�
(lict--aS"�-rJI-x .1};ttcc)
�1.}tll <: principal ptacc ofbusincss/residen c at
(Sac:Uci ty/naicIn P)
do hereby certify, under the [)?ills aad penalties of perjury, ,,J'l
( ) I aiv, an employer providing the tollowint worker's comncns:::]on covc;�_,c for Illy
enuptoyccs wor-dng on tills job
(L-,L�iLr=czw Coo=-y) — CPcLc.
( ) I am a sole proprietor, general contractor or homeowner (cuc;e o:Ie) -:Id lla\'t hired
the coop actors lister below who h2ve the `0H0V';l:'P- policies
of COLIM 0101) mc_r) ( vmfi .iion Date)
(Name of Contractor) (Inntranc Compan)/PoLc� NmLA; !)-- (FXpif"uen Dalc)
(Name of Contractor) colur—,U)'p, ohcY Nwnb�-T) (T=xpilation Da1L)
(nal� -d?,z cr al c'x�:tfo«v__v� to i�t'ud~�uCcrvc�ci oo P�=u:a:ng Ic>ll �ci=core)
I am a sole proprietor and have no one working 1701 me
O I am a home Owner perfonum- all the work myself.
raO( pl�� b cMfc t},,.Hi Jc hoarAµw u{rj cmplay Pcioc o o"'41 s � - c tau•• oo d—IL7&of
cot nm t<b•r t!-rm t.nr''in u'alch the or oo the to tti
c- ICY-3 unG.LS:—0,- I Acl(GLI 52�1(5)� ho-m 01V fc: c cr rl-rmrt a;-y`&D-LL-
"L� of cn c.zPloy�t ucdr tlw co¢ipm.lion Act
I—3 d Ihn>copy olthin ctat.cm—i my bo forwx od to tho Dgxirtnr zf of lc",Jid Moo of lnn�for tho
covm&c vrnficriioo n.•td ffi--t L•i)tzc to coatrc'covcT Lmd union 2 SA of Mar, I S2 c:tn I-d to tha in}XUdiou of—M-1 Pc -rbi
000a.r.S of s C1DC GNP to S I-5W.00&r Nc r il�x of up to one ycv t-rA 6�) to fcxm of a Stop Work Order end
fim of S I i day Lpum-t zK
A iQ��� Fcr dcvnr:,.�u,c Doty
Pc-rout Ntuvbcr
/9i 4d'� _�Z•� / ivtap;t -----
Sigl)aturc of LiccnsccAIcnnittcc
SECTION 8=;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not A/p�plicable ❑
Name of License Holder : LlJ1'YZ[ /gZ�+��a�� `� � q 6-7
License Number
Address Expir tion ate
Signature �e Teleplo D
X95 - �.3oI
'!l:.Y+r, �.rw.-wga -'a��M,.,.R ...a+e°°sr� «"" .:... x.. Ly
9 Reei$ eyed� me lmp vemerit Contractors. ,R=10 Not Applicable ❑
Company Name Registration Number
Address Expiration D"ate
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 lie/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 -
SECTIONSDESCR(PTiOiNOF PROPOSED WORK(checlk llli,appli6 able)
:rt�i'.A.;�:�... «f�.3?'.,",." r'>.>.r.
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
`_[ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: CL �k /
Alteration of existing bedroom Yes No Adding new bedroom Yes 11 No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
f it idhnAo;exi'sting:: ousinf7;cornple"te the followink":
a. Use of building : One Family V _ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms y'
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.. t`t Mascheck Energy Compliance form attached?
h. Type of construction UVoU
i. Is construction within 100 ft. of wetlands? r Yes No. Is construction within 100 yr. floodplain Yes _No
j. Depth of basement or cellar floor below finished grade 9"
k. Will building confor to the Building and Zoning regulations? _ V/ Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWN ERS'QGENT,� GONTRACTORAPPLIES FOR BUILDING'PERMIT
as Owner of the subject property
hereby authorize � J�1JZ� to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date _
MINK-
P I A NA K R A VT�f , 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 u er the pains a enalties of perjury.
PrintvKarne
Signature of Owner/Agent Date
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 51 3 5- fi,-
/�U r
Frontage �}
Setbacks Front
Side L: R:— 4 L: R:
Rear I
Building Height n
Bldg. Square Footage ` %
Open Space Footage C•C�� %
(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 _� 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 V 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 ere any proposed changes to or additions of signs intended for the property ?YES
No-
IF--YES, describe size, type and location:
City of Northampton
�;Buitdirig Department C .r
1 212 Main Street i
Room 100
MAY f Northampton, MA 01060 el
phone 413587-1240 Fax 413-587.1272 PiotfSlte P a
a O�e�Sp Cl s
_APPLICATION TO CONSTRUCT-,'ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This s' coon be m
to copleted by officek
tie`
Map � Ldt al�� i � nit�s
x
ZoneOverlayDistrict4 _ .<.
Elm St. District ?. CB-Distract
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED°AGENT
2.1 Owner of Record:
P IAPA KRN OT 4
Name fn Current Mailing Address:
Telephone
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 ap licant
1. Building ' �,/ Coe, (a) Building Permit Fee
2. Elecirical / (b) i=atimated Total Cost of
�� Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) j`j Check Number
This Section For Official Use Only
Building Permit Number:- Date Issued:
Signature:
Building Commissioner/Inspector of Buildings, Date
File#BP-2003-1080
APPLICANT/CONTACT PERSON EDWARD GODLESKI
ADDRESS/PHONE 43 CRONIN HILL RD (413)247-9782
PROPERTY LOCATION 487 AUDUBON RD
MAP 05 PARCEL 063 001 ZONE RR
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: CONSTRUCT 6 X 11 BAY EXTENSION
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included:
Owner/Statement or License 069077
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 Co ssion
2-CiC" 1
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.
5.
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487 AUDUBON RD .. •K'
Gls#: COMMONWEALTH OF 1VI BP-2003-1080
Ma :Block. OS-063 MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1080
Proiect# 15-2003-1711
Est. Cost:$14400.00
Fee: J, o. PERMISSION IS HEREBY GRANTED TO:
Const. Class: 5B Contractor:
Gr_oun• R4 License:
Use
EDWARD GODLESKI 069077
Lot Size(s4 ft 1 22591_60 Owner: JEFFREY B&nrANA L
°'�i`�`-' `�'` jonlicant: 1=D1AhARD GODLESKI
A7: 487 AUDUBON RD
Applicant Address• Phone:
43 CRONIN HILL RD Insurance:
(413) 247-9782
HATFIELDMA01038
ISSUED ON.612103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 6 X 11 BAY EXTENSION
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# i4�j L F5- p -
Foundation:
Driveway Final: Co r /Q .O
Final: Final:
Rough Frame:
OK 7— 1Q o�
Gas: Fire Department
Fireplace/Chimney:
Rough: Oil: D'
Insulation: i� K 7-- (Q -B 3 ✓�
Final: Smoke:
FinaLQk � --43 ,7/"
THIS PERMIT MAY BE REVOKED BY THE CITY OF ORTHAMPTON.UXDXLIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Si nature:
Certificate of Occu an
FeeType: Receipt No: Date Paid• Check No Amount
Building 6/2/03 0:00:00
1061 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
s