31B-167 (5) t BP-2003-0196
GIS#: COMMONWEALTH OF MASSACHUSETTS
.K CITY OF NORTHAMPTON
Lot: -001
Permit: Building'
Category: BUILDING PERMIT
Permit# BP-2003-0196
Project# JS-2003-0360
Est. Cost: $9850.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Cyrus Newman 064690
Lot size(sq. ft.): 31493.88 Owner: SHEA JOAN t.
Zoning: URB HD Applicant: Cyrus Newman
AT. 137 ELM ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:8/28/02 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 8/28/02 0:00:00 3343 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
n
f ' f
�i orthampton
Bui i Department
2 in Street
00 100
Nortpto , MA 01060 t
Prw 41, '7.124 Fax 413.587-1272 h'q!� of
s:
m�F.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed bysoff�ce
1.1 Property Address: f -
�Ir�l MapLot � ntt � b
s
e
Zone Overlay Distrtct�� �
hl-�1��IL►�� t�
Elm,St District , CB Distract -
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT;
2.1 Owner of Record:
�►CkA;✓[J_c )�l(� e- j '1 len
Name(Print) eurrent Mailing Address-
,
Telephone
Signature i
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 permit applicant
1. Building tLQ I (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
u Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection u
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This,Section=tor Official Use Only
Building Permit Number. Date Issued:
Signature:'
Building Commissioner/Inspector of Buildings, Date,.
t •�
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 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 changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
s r
SE"^,TION 3S£rDESCRIP,lONAF P,RO'POSED:WOR . cl eck Sll licable
•�:-uv, i,na,,.�""p,Aw F.-'amu, r+rypji"Y:, ,in, h{.N
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑ 1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ` `-`�—�)C.t � ([)�j �u hell) 0i� d��-`_
Alteration of existing bedroom Yes No Adding new bedroom Yes No 11J
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet o
6IfN'evi�house an"tloratldition"to'existing housing complete,the�"foTlowirig:
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=
V
SECTIbN 8 CONSTRUCTION SERVICES
8.1 Licensed Construction u ervisor: Not
lApplicable
f ❑ /'�
Name of License Holder : C oLc`t��l .J
License umbe
(�
V
Address Expiratio IDate
Si&at e Telephone
f2e' e o e m oveme`nf Contractor .' " ' Not Applicable ❑
t:• p _
Company Name Registration Number
Address Expiration Date
Telephone
SECTI0N;1,0-WORKERS':COMPENSATION-INSURANCE AFFIbAVIT,(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completedand 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...... ❑
QNS
MU A
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 10$.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 huildini!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 M$ssachusetts 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
0
9 Grid :afwart 4aillp foil ^
aB �asattclTttsctta'
DEPARTMENT QP BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFMA.VIT
(licensq m-mittee)
with
��a principal place of business/residenee at:
` 1 t (phone#) __ '-
(str e eWci ty/state/a p)
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 wonting on this job:
�GD-4aj Iei cc-M,2i �i ► o
(Insurance Company) (Policy Number) iration 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 Numbcr) (Expimbon Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shcei ifnoocnxjy to include informllion perh ning to ell om4,,don)
( ) 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 homcowvcn who employ pc som to do m2* •,�duction or repair wvrlc on a dwelling of
not more than throe units in which the hotmowmr resides or on the groundi appurtenant iha,do arc no(gcna-ally oomidercd to be
employcra under tic-mi(ct a cc cation Act(GL152,=1(5)),application by a homeowner for a fucose cc perm may evidence the
legal etatua ofan employer under the Woricoea Compomation Ad.
1 understand that A copy of this ehtcmcut MAY be feawruded to tho Dtputmcoi of Inial Ac idea&Ofhoo of L—Umnce for dw
coverage vaifitxtioa and that failure to v—a=covccngo under soctioa 25A of MGL 152 can lead to the imposition of criminal penaities
of a fine'of up to S 1,500.00 anNor iraprisonmcnt of up to one ytar and civil pcmlti a in the focm of a Stop Work Order and a
fins 0(5 100.00 a day against tnc.
For dcput wr uao only
Permit Number
ap;f Lot#
Y '' Isi�ahtre of icensee/permittee