17C-273 (6) %-A P P
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DEPARTMENT 01" BUILDMG INSPECTIONS
212 Main Street * Municipal Bull(brig
Northampton, Mass. OIOGO
'WORICER'S CO'NITEiq.SAnO'JN m.sui2,,1Nc3? AsFMAVIT
\"qth a PrLncip,-d place of
of 0,'Z7 56r7-007&3
do hereby' ccr-'i- ' dic. ;Ind 0m;
a-m an cmp!oyei. providing th ollov'rin: COHI9C!IsaU0j3 c-ovc:*,---,.c for my
c,t2p!oyccs worldrig on t1iis job
0
(Lr,i-ramd Co Lapam-)
.- Number) (Expir-,Son Date)
am a sole i)romnetor, Yleneraii cozia-accr 'noa--�owue� \Pli de one) Pod .-vc' hired
Gon—L,')ctors hstet- beiow -'-'1-0 01-c -'-'oFke-�s C-0mutusz-12orl
(-Namc of contrnczor) (Ex!I.:.--,.:-.o.-. Datc)
(Na.mc of Cou(T-,c-,or) Date)
(Nziulc of Coriti-ac(oi) u Da i 6
(vane of Contractor) (Ias-uraDc--- COSI)7 yfjlobcv Mlml;:-r) Date)
prop!m"')v no :,Iil
NMI::plczs be tl:z,•-.v�•jc CJ -PIII
OC4 mCCC 1h-13 UU-00 U."I"in«i..di u C.:
c='Ptolfcr'3 h'xnco,,.c for L-11='=Or;>717'.!: '<rcc Lit:
Icszl r"-,,-of an c tployx UZIL:cr ILO WCVkr,'L
tl).i a copy of th,- —Y bo to of L-.d,.,,.J of!:1—�-4 for Un
()01—&c vc;i5=tion and th--t(--.dum to 2jA of'.!G1.132 can I"to Ov,i.,up'35LIJO,"1)
i-Tt''13 of a f'us-of up to 5 1-M.0)Z:'-ffry 0.(!:;)to rr'- r.i evil-"-MIticz M do r6on C.f 'st�"
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /r (" f _ �; j'�� 1 t.+ /,._
License Number
Address / j Expiration Dale
ignatur7 Telephone
9'Registered Home Improvement Contractor „ •..F _. ,. Not Ap,Acabie ❑
Company Name Reji tra Ion Number r
Address Expiration Date
MA—Telephone/X11
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.
t Signed Affidavit Attached Yes....... No...... ❑
11. = Home Owner `EYemntion
77je :urrcrit exemption for"homeowners"was extended to include Owner-occupied Dwellin(�L of one(I) 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 wiil be required from time to time,during and upon
completion of the work for which this permit is issued.
dso be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 3 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable for person(s)
ou hire to perform work for you under this per-mit.
`hhe undersigned"homeowner"certifies and assumes responsibility ibr compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachuserts General Laws Annotated.
lfomeowner Signature
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1..
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows I Alteration(s) ❑ Roofing
Or Doors ,Dia
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [ice Siding [pj Other[01
Brief Description of Proposed/
Work: Lhri�-r^ IG 10L� �� .�' �" Lr✓ll +��C��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sat If New>house-and or-additton to--existinq-hogs i4,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
I, r---ef as Owner of the subject
property rr� / t,
hereby authorize �] G l7 i"j ) Q/,-7
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the f 6regoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print 'ame ��
gnature of Own ! gent Date
^
. . .
Section 4. ZONING All Informatio'n Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be Filled ir,',),v
Building Department
Lot Size
Setbacks Front
Rear
Height
- .
Bld,-,. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
Fill
A. Has aSpecia| Perm it/Vahance/Findiny ever been issued for/on the site?
�� ��
NO \_/�� DON'T VV \_/KNOW YES \_/
IF YES, date issued: !
IF YES: Was the permit recorded at the Registry v/Deeds?
NO /—> DON'T /—\ YES /—�
`� _�� ��
IF YES: enter Book Page and/or Documenc #�
B Does the site contain u brook' body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need tobe obtained front the Conservation Commission?
Needs tc »eobtained /-� Obtained /—� Da�s |oucu� -------------
\_/ �
C Dn any signs exist on the property? YES /—\ 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 �-\ NO
�_/
IF YES, describe size, type and location: �
E. Will the construction activity disturb(clearing, gradingexcavation, o,filling)over I acre o,isx part.ofu common plan
that w|x disturb over 1acre? YES ( ) - NO �`_/\
``� /
/F YES, mco v Northampton Storm Water Management Permit /rommo oPvvin roroireu.
-
- 'Uepartmentuse only
City of North,ampton 5r�tds of Pe t
Building Department Curt,C;ut Dri�o� ay Permit
212 Main Street ISe,,%,&/Septiq Availability
ROOM 100 Water[Well Avalability
•; a �« `,
Northampton, MA 01060-1 T o SI its of S=tructural Plar%s
phone 413-587-1240 Fax 41"a,587,"1272
PPL" ;�TIUN TO CONSTRUCT,ALTER, REPAIR, RENO C r� L P.4 'y� `ri JE C)rt TWO FAMILY DWELLING
! SECTION 1 -SITE INFORMATION
ti-ii to be completed by office
1., PrODeriV Address'
Lot_ - —Unit
.� Y • Zone Overlay District
Elm St.District __ CB District_
SECTION 2 -P1;0PERTY OWNERSHIPIAUTHORIZED AGENT
I
2.1 Owner of Record:
FG�?CJ' �u '�... -
Name(Pnnt� ;urrent ( any less-
Si.: [ur•: �
I Z.' :,uthorizcd A��ent: '
(Printer- t Q —x(
I r ..�
SF(,'.�--- ..:Iot_�=��:z'IMATED CONSTRUCTION CASTS
Its' rn Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 uild'n� r (a) r�I,dl _ ll("miit Fee
2. l u � osL of
3. i 'umuine �� 3ui1ding Per.riit Fae
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I -.- ,,,r.an --'dAC)
This Section For Otticia( tJsc Or,hd
Date
Eui ding Permit N.,mber.
r '
Building Commissioner,'Inspector of Buildings Date
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BP-2009-0586
GIS# COMMONWEALTH OF MASSACHUSETTS
iicc. 471 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-2009-0586
Project# JS-2009-000841
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITH HAMILTON 133811
Lot Size(sq. ft.): 5096.52 Owner: LAVALLEE RICHARD J&EDWARD DUPRE& SHARON DUPRE
Zoning:URB(100)/ Applicant: KEITH HAMILTON
AT. 27 LILLY ST
Applicant Address: Phone: Insurance:
17 ORCHARD ST (413) 587-0763 O WC
EASTHAMPTONMA01027 ISSUED ON.121912008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS/DOORS
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 12/9/2008 0:00:00 $35.007592
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo