43-052 (3) 516 WESTHANII'TON RD ` ' E3p-2001-
{
GIS#: COMMS � AM
e.
MWp:Block:43-052 `
Lot:-001
Permit: Building
Categn:_renovation UlL .
��E:
Permit# BP2001-0196
q
Project# JS-2001-0319
Est.Cost:$1200.00
Foe:$50.00 PE�R' t. ` I01YI HES rs TO.
Const,Class: contractor-
Use
ontractorsUJ a Group: `
Lot Siz&fAq.ft.k 40772.16 STOKES TIM
zoulau:sR AN1q- [ -
____
1' . � , A 1 PTO'
A„pnlieantAddressc Phone; Inse�
516 WEST'HAMPTON RD , 413 582-0474
FLORENCEMA01062 SED O..*B/ZS!(1d *10
TO PERFORM THE FOLLOWING WORK: ONSTRUCT NEW DORMER IN ST
BEDROOM _,
a
POST 1M CAM O IT IS VISIBL OMT11A
T
Inspector of Plumbing Inspector of Wiring' D.# V Inspector of Buildings x`
Underground: Service' Meter:
Foodu
w g
Rough: Rough: House f Foundation:
Final: Final:
Rough Frame. dvAr J.
Gas Fire Dgg�prt .Ind Firepiacatchimney:
Rough:
Final: Smoke: Final: '
THIS PERMIT MAY REVOKED BY THE CI OF RTHAIMPTON UPON VIOLATION
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occugancy Sj nut' :
ee a Receipt No: Date Faid: Q k Now "OHOU
r
Building 8/25/000-00")0 1053 $50.00
212 Main Street,Phone.(413)5 1240,Fax:(413)587-1272
B ft Commission -AnthonyPatille
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516 WESTFJAMPTON RD BP-2001-0198
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mam8lock:43 -052 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2001-0198
Proiect# JS-2001-0319
Est.Cost: $1200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 40772.16 Owner. STOKES TIM&ANN LEWIS
Zoning: SR Applicant. STOKES TIM & ANN LEWIS
AT. 516 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
516 WESTHAMPTON RD (413) 582-0474 ()
FLORENCEMA01 062 ISSUED ON.-8125100 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT NEW DORMER IN MASTER
BEDROOM
POST THIS CARD SO IT IS VISIBLE FROM THE 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 Paid: Check No: Amount:
Building 8/25/00 0:00:00 1053 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0198
APPLICANT/CONTACT PERSON STOKES TIM&ANN LEWIS
ADDRESS/PHONE 516 WESTHAMPTON RD (413)582-01474 Q
PROPERTY LOCATION 516 WESTHAMPTON RD
MAP 43 PARCEL 052 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT NEW DORMER IN MASTER BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessoly Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 C ission Permit from CB Architecture Committee
Signature of Building fficial 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.
z
0 - J
City of Northampton
AW
2 ( Building Department
212 Main Street
EFT OF cStJ'l�[� ,�" 1rrl`Tl":1NS
Room 100
P40PT!jl^v,,-0111. �'� _.�., Northampton, MA 01060
phone 413-587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-'SITE INFORMATION
�r Phiso � orr�ptete 'offce
1.1 Property Address:
S 16 W
F
-�y �s
b Zf o �y ��?y r rf District
Vlr�l(IS
10A7,
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wY � t 4�,
SECTION 2 PROPERTY OWNERSHIPIAUTHORIZED AGENT
X22..11 Owner of Record: �,
/a') 1i 1 S S (Ci W
ame(Prin Curr t M 'ling Address:
e Sgz" 0A—i 4
Te r
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) Building Permit Fee
l QUO. 0 a
2. Electrical (b) Estimated Total Cast of
Construction.from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 + 4+ 5) Check Number Lot 6 --'
This Section,Fa Official Use Only
Building Permit Number: // 44
{ (Date Issued:
I
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
q Building Department
Lot Size 0 1�
Frontage
Setbacks Front
Side L:9d R: 60 L: R:
Rear 1001
Building Heighti 1
2-4 --o
Bldg. Square Footage %
Open Space Footage �t
(Lot area minus bldg&pavedt91 UV 0
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 _ Q 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 0
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:
ek
D. Are there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
CN 5- D C PTIO OF eRO09SED WORK chid I
New House ❑ Addition ❑ Replacement Windows Alteration(s),V Roofing �f
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work Z "�sA
Alteration of existing bedroom Yes No Adding new bedroom Yes < _No
Attached Narrative y9 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet%
-INA -
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?
Type of construction �1401 �
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 A 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 atters relative ork authorized by this building permit application.
q6U 2) Zoo
Sign ture o ner Date
a Owner/ uthorized Agent
hereby declare that the statements and information on the foregoing application are true and acc o the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Ti � � ..,, '' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE:AFFIDAVIT(M.G.L.c. 152,§250(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.
L.SiL)rned 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 108.3.5.1.
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
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Ttpr
Grit� Of
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4
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(ficenseepermittee)
with a principal place of business/residence at:
(phone#)
(street/city/sta&zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
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 Company/PoLicy Number) (Expiration Date)
I f.
' (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(auacn additionsl sheet ifnaccssary to imetude information pertaining to ell 000hraclors)
( ) I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcownes who employ pc=m to do maiatmaac,construction or repair work on a dwelling of
not more than throe units is which the homeowner resides or on the grounds appurtenant tbardo are not generally eoosidard to be
employr:rs under the woc cr's con4=s4on Act(OL152,ss 1(5)),application by a homeowner for a license or permit may evidcaoe the
legs1 status of an employer under the Worko's Compensation AcL
I understand that a copy of this r atemeat may be forwarded to the Depwtll o of Industrial Aoeide cts'O>Eoc of lnsL oe for the
coverage vaification and that failure to saute coverage under scctioa 25A of MOL 152 can lead to the impos6on of criminal pmal ies
ooasistiug of a fine of up to S1,500.00 and/or imprison of up to one ytw and civil pcnsltia in the form of a stop work Order and a
firm of s 100.00 Icily against ax.
For dial use only
Permit Number
Map# Lot#
Signawre of LicensedPermittee Date
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