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Section 5. Narrative/Description of proposed work to be performed at 58 No. Main Street,
Florence, residence of Robert Stewart and Susan Waterman:
1. To change existing bedroom into bathroom and closet by adding wall; removing plaster and
lathing from exterior walls, lowering ceiling, adding insulation, and drywalling all walls.
2. To remove plaster and lathing from exterior walls, lower ceilings, add insulation, and drywall
all walls in the dining room, living room, den, first- and second-floor hallways, and three
remaining bedrooms.
o�1tt/MP�O
NLIztilaillpfnll
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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORTCEIR'S COMPENSATION INSURANCE M A.VTT
(li cen_ser/permi ttec)
vvith a principal place of business/residence ay.
_(phone#)
(s t1-eei/ci ty/staieJzi p)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following v;orker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( I am a sole proprietor, general contractor o homeowner * cue one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurancc Cornpany/Po6cf Number) (Expiration Date)
a
(Name of Contractor) (Inssurancz Compaml/Poticy Number) (Expiration Date)
(Name of Co ctor) / (Instrancc Compaily/Poucy Nutuber) (Fpiration Date)
rac� .�f�v, d,,
(Name of Contractor) (Insurance Comr=y/Poticy Number) (Expiration Date)
(attach additiooal z!xci tfneccssary to include infoanation pertaining o all ccc&-'c�nrs)
( ) I am a sole proprietor and have no one .vorking for me.
( ) I am a home owner performing all the work; myself.
NOTE:please tx awwt that while homcowz�cra who cmplay pcsaar to d)¢uaiutcnanc,con n u oa cr rrpair work on a d«clliag of
not moee than thrco unite in tk-xicft the 1xomooavcr rm :3 a oa the E Dune's zplxrrtcne rt the Ro ate not gcr>crnity ooasidacd in tx
emploYas Undcr the WOrkce,ration Act(GI-152,m 1(5)),r4plica6cn by a homcow=for a liccrne or permd may evidence the
legal ctatua of an employoc under the Worlccla Compemat AnL
I understand that a copy of thin eratcmeat may be forw.uded to tbo D:partasast of Industrial Accideoiy Offroe,of Instuinco for the
covcngo vaificaiion and that failure to azure covet-ego under scctioa 25A of 2IGL 152 can Icad to tho imposition of a imi W pca&Wcs
ooasistutg of n fine of up to S 1,500.00 arWor imprisonment of up to ecx yrar end civil pm 16a in the foam of a Stop Work Ord--and a
fins of S 100.00 a day agniaA m-_
'Al Z_ Foc&P-�"Daly
Permit Number
Mag S Lot#
tgnature of Liccnsec/Permitfee e
SECTION 8'-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Applicable ❑
Re s"tered"t "bme" marovement Contractor.d
Not
Company Name Registration Number
Address Expiration Date
Telephone
SECTION;lO--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...... ❑
tt,_.. � 01I' 11,Wmlmng e Whem ra -
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 aitV Local Zonin<� State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5' �..
DESCR'IPTION3[OF PROPOSED WORK(check all apalicable)
New House ❑ Addition ❑ Replacement Windows' Alteration(s) 9 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Dftks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: a C/6 Set
Alteration of existing bedroom V_Yes No Adding new bedroom Yes No
Attached Narrative 9 Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet o
sa�If New h'"ous`e aril or add`itiori`to ezistJh Ifd isilnk,:ddhJ01ete the followij° :
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?
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
as Owner of the subject property
hereby authorize 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 foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of-perjury.
- Print Name ,
Signature f 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
1 This column to be filled in by
ti�+ 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 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
IF YES, describe size, type and location:
D. Are there any proposed change-s to or additions of signs intended for the property ?YES=
No
IF-YES, describe size, type and location:
V-iky of Northampton ==Mail oP er
..-ji >Ilding Department CrbC4
[--" 212 Main Street Sewer�k ie at a;
��r �' ' ^. Room 100 V�JateWeh �v
Northampton, MA 01060 7iwoSets�A
_pho5 4113-57 1240 Fax 413-587-1272 Plot/Slte1, a
i Qther 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 m
be,copleted by office
,p Map, Lot Unit
0(0 Zone Overlay District
( ►VI
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ry,
N me(Print Current Mailing Address: '576 aaS] —
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 applicant
1. Building a/ OBo (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
1 Construction from 6
3. Plumbing �.�! `do Building Permit Fee
4. Mechanical (HVAC)
5. Eire Protection
6. Total =(1 + 2 + 3 + 4 + 5) ( 00 Check Number owv r
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0466
APPLICANT/CONTACT PERSON STEWART ROBERT&SUSAN WATERMAN
ADDRESS/PHONE 58 NORTH MAIN ST (413)586-2252 Q
PROPERTY LOCATION 58 NORTH MAIN ST
MAP 17C PARCEL 258 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 11L _
Fee Paid a
Typeof Construction: REMOVE PLASTER&SHEETROCK CHANGE EXISTING BEDRM INTO A
BATHROOM&CLOSET
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LLOWING 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 C ssion
10111/` 00, 160 2e—
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.
58 NORTH MAIN ST BP-2003-0466
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17C-258 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0466
Project# JS-2003-0786
Est. Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa. ft.): 23870.88 Owner: STEWART ROBERT&SUSAN WATERMAN
Zoning:URB Applicant: STEWART ROBERT & SUSAN WATERMAN
AT. 58 NORTH MAIN ST
Applicant Address: Phone: Insurance:
58 NORTH MAIN ST (413) 586-2252 O
FLORENCEMA01062 ISSUED ON:1118102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE PLASTER & SHEETROCK, CHANGE
EXISTING BEDRM INTO A BATHROOM & CLOSET
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/8/02 0:00:00 228 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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58 NORTH MAIN ST BP-2003-0466
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17C-258 CITY OF NORTHAMPTON
Lot: -001
Permit: B u i I d i n a
Category: BUILDING PERMIT
Permit# BP-2003.0466
Project# JS-2003-0786
Est. Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 23870.88 Owner: STEWART ROBERT&SUSAN WATERMAN
__. -�Wit__-_i f i 1 • - - J.V 4� ,I Y I i A
AT: 58 NORTH_ MAIN ST
Applicant Address: Phone: Insurance:
58 NORTH MAIN ST _ (413) 586-2252 O
FLORENCEMA01062 ISSUED ON:1118102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE PLASTER & SHEETROCK, CHANGE
EXISTING BEDRM INTO A BATHROOM & CLOSET
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.'iA'. Building Inspector
Underground: Service: 2 1 tj 0z' 0013' Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final: 4lll1��
4 �nr Rough Frame:
Gas: Fire Department Fireplace/Chimney: �-•t 8�p
Rough: Oil: Insulation:
Final: Smoke: Final:QK
THIS PERMIT MAYBE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA TIO F
ANY OF ITS RULES AND REGULATIONS. _J
edCertificate of Occupancy ' Signature•
Fee Type: Receipt No: Date PP_d- Cbeck No: Amount:
Building 11/8/020:00:00 228 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo