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DEPARrME1-rT OP BUILDrltC INSPPCrONS
212 Main Street ' i11unieipnl Building
Northampton, Mass. 01060
«'O RICE it'S CO'MT NSAnON, MSURA.NCF AFMA� �- '
(tjcnscr/pcTm,tlrc
�S'(T_rr.Ucity/SL8LGr7 P)
do hereby cerdi ,, under Lhc pains anti penalties of pcOUTy, hai
O I am an employer providing the following �korkcr's coinoe:isado cove-C for Iny
eluployecs tivorlang on tills job`
OmsuJ-anc-- Comp-am,) (Folic:l;u-nabcr) (rxpint on D2k)
( ) l am a sole proprietor, general contractor or homeowner(ci:cie or!e) and have hued
the coau-actors listed below wbo have the folloxving worker's camjen_abon poticies:
(Namc of Conn-aor) (inRraw—c Compan)vi'oi:ic; NUZz M-) (Explmt:el'D mc)'
- (Name of Coacraaor) -- sar
Rasanc Comany/PoUc; Nrum cr) Cspirzaion Due)
(Name of Connaelo,) (Iasuranc; Comm-/PoUcy Number) . (Emm'M-6oa Date)
(Name of Contractor) (Insurancc ComparryRoUcy Numb-cf) - 'Expiration Date}.
(Lax&addiioc j 6cd if oac*)C r}•to;W=udc iarerm+:ioo pensiains to..0 ooa7reoa)
i
r
'I am a sole proprietor and have no one woriong for me.
( ) I am.a home owner performing all the work myself.
NOTE'Pt—beLM thw wt lc bomcvwmm wbo o=ploy pes.om to Sa A= ==Zrz= o c rc xi rk oo.d-cirmE of
ca wcxm ILL'n thrm=iu to wbicb Ibe bamoawmr rIIl�or oa rib c voua ti, 2.7 U Cn=CL rbC e%o CT OC K CC3MMO.OOCf�d-"'ri�to LAC
®ploy--i ttm--ks c=p=z:Una Am(GLI 12-=1(5)},x.ppli=600 try a bomaoavc for s Gccr_or Pao^ra:y c%'dco=the
IeVI n a^„of as-=ptoyw modes tic Workce.Coc*oc as Ass.
I uaderaAzd that a copy or dbu c=,oco ox may to for,. Id to tbo Dopantacsst of Iodu�d AcodamY OTAi or l6A�fa the
ooven:ge VU Z=2100=W Uu fmiltae to S,==loov=%gc I1DdCY souiou 25A of MOL 111 ezo laid to the imrpositioo of aimiml Peaaltio
oo=asu g of a rmc of up to S I yoo.00 sswcw,bx pri==me t orup to mx y=end a%il pcoal-oo io 6c form of.Stop Wort;order and
fIW 0(5100.00 a dty apiOg me
for dcq.nt:r-...-}1 v,c ody
Permit Numbc-T
7 6 Lot
Signawllof t crmiucc
A
+ 1
f
' 1 'C7 Ste° � � �..s`—`... �f��-t''�-'1:., fit.��
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SuDervisor Not Applicable ❑
Name of License Holder: 64�-
License Numbe
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Regi7710 Nuumm er
/or
Address l 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...... ❑
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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) F-1 Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[O] Other%h
Brief Descripti n of ppropo d �PP Rl 'e a -tG ,S A,r.'!� fi'''t,,, �^'3' �O�S� R e ���r/ltd,,T �,A
Work: au.of a
Alteration of existing bedroom Yes_f/No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. 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.
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
W1 �- E S : v; I as Qa aft f the subject
Fbyau
orize i A,/c4e n y behal, in all matters re ati to wo authorized by this building permit application.
—- CS '
Signature of Owner Date
I, ft'rp .fl���t as Owner/Authorized
Agent hereby declaml that the sta ments 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 Nam
1-d'
Signatur of er/Agent 6ate
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 Q DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW Q YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES o NO 0
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 WaterNVell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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 Overlay District
Elm St District CB District
SECTION ROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 ne�r-�of ecord: OF
e(Print) Current Mailin Address:
SSr %-7
Telephone
Signature
2.2 Authorized Aae4
Name(Prin'O. 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 OD
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
l`1 {
4. Mechanical(HVAC) / 1-7 0 �„ V
5. Fire Protection "t
6. Total=(1 +2+3+4+5) OZ. Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Bu ings Date
1
JUL 9 2007
DEPT Or E ;,C;;'G lifS+'fit i 'iS
O1060
File#BP-2008-0035
APPLICANT/CONTACT PERSON Craig Marney
ADDRESS/PHONE P O Box 128 LEEDS (413)586-5512
PROPERTY LOCATION 21 NORTH MAIN ST
MAP 17C PARCEL 254 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fke Paid
Lf3uihling Permit Filled out
ee Pahl A "7
Typeof Construction: Repair porch stairs and porch floor
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
,RM 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 Commission
6 7 r•1
Signature of Building Of icial 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.
. BP-2008-0035
GIS#: COMMONWEALTH OF MASSACHUSETTS
M4p.Bliek: 17C CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0035
Project# JS-2008-000044
Est. Cost: $3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Craig Marney
Lot Size(sq. ft.): 28488.24 Owner: SHEA TIMOTHY E TRUSTEE
Zoning: URB Applicant: Craig Marney
AT. 21 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O Box 128 (413) 586-5512
LEEDSMA01053 ISSUED ON.711112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-Repair porch stairs and porch floor
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 7/11/2007 0:00:00 $50.004702
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo