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38A-090 (3) G t f Northampton B Zing Department Main Street oom 100 a e „ + No pton, MA 01060 Set phone 413 587. 240 Fax 413.587-12725ite � 6UI! 'ic N23 I-cl IONS Q e "7�I TION TO.CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to begcompleted by'office 1.1 Property Address: wr ' ;.-7 Map Lo x Unit Zone Overlay DIstr, Elm'St. District CB°District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P 'nt) Current Mailing Address: (f,ys�6L• Telephone—, -c-j S d/o 47-L Signatu S - 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION13 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only com leted by permit applicant 1. Building G 6 G (a) Building Permit Fee' G 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 Jqql I—Xq,'06 .This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector 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 �7 13, ),3 9 �/1�/6VZ Frontage �t ,) S- 3 I j Setbacks Front a1 / �,� G7 Side L: R: L:/7 R: l� /`��� Rear 113 Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved G )d 1,3,3 parking) / (.r #of Parking Spaces `Y Fill: volume&Location N A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: 11b iGt l IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Sof° e^J fY.s" Page 1 141'� �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 Com mi slo ? Needs to be obtained Obtained 1C Date Issued: C. Do any signs exist on the property? YES NO k 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: SECTION 5 DESCRIPTION�OF PROPOSED WORK(check�all'apalicable) New House 1K Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: t1i w ?"� i—�" L t - v "-K T Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a �IUN ho a�titl o additi"on.to existing dousing,=complete`11b'd 16116 F! a. Use of building : One Family _ Two Family Other b. Number of rooms in each family unit:_ Number of Bathrooms �_ J C. Is there a garage attached? .� d. Proposed Square footage of new construction. ?6 Dimensions 3•X+(? `� �� �' �C� cs�t)I e. Number of stories? f. Method of heating? Ccfis Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. �.� Mascheck Energy Compliance form attached? h. Type of construction J%% C,4 t I- �,�• ;zvn/ 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 •j k. Will building conform to the Building and Zoning regulations? _ t 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 l �vr as Owner of the subject property 1 hereby autho ize 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 th the statements and information on the foregoing application are true and accurate, to the best of my knowledge and be ief. Signed under the pains and(f' penalties of/perjury. Print Name 44�� /0 Signature of Owner/Agent Date SECTION 8'-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : .�� /1� S �/T �4� t- ` Y © r)— 'tC Q License Number f 6. 3 Address Expiration Date Signatur Telephone W�,Regffle edMM, mpro+rementtr.Contractor= � r Not Applicable ❑ Company Name Registration Number Address 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....... 14 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 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 � r 4't t1Al'f PJO s e Cr # of wart 11ttnip#111 B 6 �aiaacflasctta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPEN SATION INSURANCE F, 1 AVIT (li cep see/permittee) with a principal place of business/residence at: (phone#) (6 trrxi/ci ty/stateJa P) do hereby certify, under the pains and penalties of penury, that. O I am an employer providing the following worker's compensation coverage for my employees worming on this job: (Insu=ce Company) (Policy Number) (Expiration Date) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Cornpany/Poticy Number) (Expiration Date) f. (Name of Contractor) (Insurance Compa ry/Policy Number) (Expiration Date) (Name of Contractor) (Imurance Compaay/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach aciditionil s1uc2 ifncccsury to in�udc info�TniIIon pcsYa-icing to all coc�Srad4ts) O� I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plcnsc be aware that wtnlo hoaicovtxta who employ pGrom to do maintcaanc coasts ction or mpair work oo a dwelling of not mote than throo units in which the hornoowncr sides or on tho group.s+ appurtaiani thacio artnot Ecacrally ooasidcrcd to be rn�plo}�xa under the worker's ocnc sction Ad(GL152,"1(5)),application by a homcow=for a liccasa cc pamd may cvidcace the legal YW"of an omployer under the Workces Compomatiou AcL I understand thsa a oopy of this etatcmcat may be forwarded to the Dcyart.c of Iodu trial Aaidca&Offioo of Inn;,-for tho coverage verification and that failure to s=ure coveatgo under section 25A of MGL 152 can lead to tho impo on of aimiwl pcna cs oomisting of a fmc of up to S1,500.00 and/or of up to one year and civil pcaaltia in the form of a Stop Work OrdG and a fano oCS100.00 a day against me For dqurtaium only ' Permit Number awlrJ lC a„Z Map t Lot# Si of Li � ccnscx/Permittee lea 4 L o 1 C�� Aip 41 ov 1 -90 Permit No. D19-03 4r H i LJ CITY OF NORTHAMPTON, MA j DRIVEWAY PERMIT _. Date: 10-03-02 FEE: $25.00 CHECK#: 2022 THE BOARD OF PUBLIC WORKS The undersigned respectfully petitions your honorable body for: Permission to install a driveway at 209 Grove Street Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All drainage shall be directed off the driveway surface to adjacent land and not/on the existing roadway. Driveway surface to be paved if the grade of the proposed driveway exceeds 3% or more. By: AWnes M. Harrity 585-8625 77 Maple Street, Florence, MA 01062 Telephone #: 413-585-8025 Proposed Location Inspected By: Gravel Base Grade Inspected By: #pmval S J THE BOARD OF PUBLIC WORKS voted that petition be granted. l2 • r 2 goy y� George Andrikidis Director of Public Works (SUBJECT TO ATTACHED CONDITION 1 & 2) cc: Building Inspector �c Permit No. D20-03 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 10-03-02 FEE: $25.00 CHECK#: 2022 THE BOARD OF PUBLIC WORKS The undersigned respectfully petitions your honorable body for: Permission to install a driveway at 213 Grove Street Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All drainage shall be directed off the driveway surface to adjacent land and not on the existing i roadway. Driveway surface to be paved if the grade of the proposed driveway exceeds 3% or more. ,. By: /'/ ate. J es M. Harrity 7 Maple Street, Florence, MA 01062 Telephone #: 413-585-8025 Proposed Location Inspected By: Gravel Base Grade Inspected By: Final Approval THE BOARD OF PUBLIC WORKS voted that petition be granted. George Andrikidis Director of Public Works (SUBJECT TO ATTACHED CONDITION 1 & 2) cc: Building Inspector - 0 Permit No. D19-03 4 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 10-03-02 FEE: $25.00 CHECK#: 2022 THE BOARD OF PUBLIC WORKS The undersigned respectfully petitions your honorable body for: Permission to install a driveway at 209 Grove Street Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All drainage shall be directed off the driveway surface to adjacent land and not;on the existing roadway. Driveway surface to be paved if the grade of the proposed driveway exceeds 3% or more. By: JYnes M. Harrity 585-8025 77 Maple Street, Florence, MA 01062 Telephone #: 413-585-8025 Proposed Location Inspected By: —D . Gravel Base Grade Inspected By: 0 D Final Approval THE BOARD OF PUBLIC WORKS voted that petition be granted. �z • r�2,o7, f C. 6e- lawcl-t George Andrikidis Director of Public Works (SUBJECT TO ATTACHED CONDITION 1 & 2) cc: Building Inspector