38-052 ' y
39 LAUREL ST BP-2001-0732
GIS#: COMMONWEALTH OF MASSACHUSETTS
M .Block: 38-052 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofin ]BUILDING PERMIT
Permit# BP-2001-0732
Proiect# JS-2001-1381
Est.Cost:$3500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group W M Brown 038426
Lot Size(sq. ft.): 26397.36 Owner. RAY JOAN C
zoning URB Applicant: W M Brown
AT. 39 LAUREL ST
Applicant Address: Phone: Insurance:
177 West St (413) 247-9937
WEST HATFIELDMA01088 ISSUED ON:3/2000;1 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING LAYER
POST THIS CARD SO IT IS VISIBLE FROM THL STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 Pard: Check No: Amount:
Building 3/20/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
4
`-- 4Ro
orthampton
MAR Z� �BuiDepartment
ain Street
m 100
DEPT OF BUILDING IMSP"Va m p o n, MA 01060
NORT_ MAA(%05R7 1 40 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 11—;SITE INFORMATION
�i
1.1 Property Address: .1
!=X'7.1
1.1
� 6 l^.
3 g ac, '1 eRhl Map
L. f � i ss
AD
a s k/ s 1r fYs
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na J(Print) Current Mailing Address:
ddW C' . lea Telephh`o�ne IW/I,
b
Signature *j 5*,r'f^ 7P6�
2.2 Authorized Agent:
ul, r b apK7 j 77Tyiezt �ku
Name(Print) Current Mailing Addres :
.Ae"Ib/ofi-o Y/ - ?gni 7
Signature > Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COST
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
' - a
2. Electrical (b) Estimated Total Cost of
Construction from,, 6
3. Plumbing Building Permit.Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) Check..Number
Thlis Section For Official Use Only
Building Permit Number: ate Issued:
Signature:
Bolding Commissioner/inspeetor.of Buildings 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
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 elver 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 changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
RF. TIONDE P O II I't ble
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing e
Or Doors 0
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other( ]
Brief Description of Proposed Work:0,dadLgA,r;t,'L", ercar� i,.�u�1'yr�g Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a. Use of building: OneL 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?
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 P RMIT
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
I, I AA/, as Owner/Authorized Agent
hereby declaretwat 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.
(S
Print Name
��.��a,r r3.' Q31 J3 !9/in I
Signature of Ow'Ter%Agent IDA
SECTION,8=`.C+ONSTRUCT OR). SERVICES
J.1 Licensed Construction
Supervisor: Not Applicable ❑
Name of License Holder : M p?t W./
License Number
McfrEfss Expiration Date
Signature Telephone
F E ",'1,:. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT 01:10-1NIr1RKERS'COMPENSATIONS INSURANCE AFFID VIT(M.G.L.c.152,f 25C(6))
Workers Compensation Insurance affidavit must be completed aind 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. 51.
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 hoine 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 bgildina 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
��� Teti Crx of Xart4 ulv f ou
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
No1Ahampton, Mass. 01060
i
WORICER'S CONTENSATION INSURANCE AFMAVIT
(licenseelpelmittee)
with a principal place of business/residence at:
t 27�Y� r tel. ,�p�,Q4� o 1&VT-- (phone#) yr3
"'�"'.
street/city/stalr/21p)
do hereby certify, under the pains an4 penalties of pedJury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
if
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am le pro2rietor general ontractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (hlsu#nce Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insu#ance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insujrance Company/Policy Number) (Expiration Date)
i
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addi$oml*beet if necessary to inchxhe infoctw�ion pataining to all oodradors)
i
(V I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcz be aware that while homeowners who employ persons to do maintenance,wastry oa or repair work on a dwelling of
not more than throe units is which the homeowner res{des a on the grounds appurteala lherdo arc not Seactaily comidcr ed to be
employers under the work,ees compensation Ad(GLI:52,-1(5)),application by a homeowner for a license Or Permit may evideam the
ltpl status of an employe under the Work*?*Com;},N on Ad.
I understand that a copy of thi*rul=wat may be fmvi ended to tbo Departa�of Industrial Aocidmts'O$oe of Wxx*nce for the
coverage verification and that failure to sec=covergga under socdon 25A of MGL 152 can lead to the itttposihon of criminal penalties
cowl-emg of a fine of up to$1,500.00 andlor imptugam�of up to one year and cava pcmWcs is the form of a Stop Work Order nerd a
flue of S100.00 a day against rte.
For dial use only
Permit Number
1 3/19/e� Map# Lot#
Signature o Li er'rni Mt