31B-167 (6) f
BP-2002-0978
GIS#: COMMONWEALTH OF MASSACHUSETTS
� tB_167 CITY OF NORTHAMPTON
Lot: -001
Perrnit: Building
Category: BUILDING PERMIT
Permit# BP-2002-0978
Project# JS-2002-1582
Est. Cost: $1700.00
Fee: $10.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 3 149 3.88 Owner: SHEA JOAN L
Zoning:URB HD Applicant: SHEA JOAN L
AT. 137 ELM ST
Applicant Address: Phone: Insurance:
137 ELM STREET (413) 584-5008 O
NORTHAMPTON MAO 1060 ISSUED ON:5/16/020:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE INGROUND POOL * FILL
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 5/16/02 0:00:00 19371
19371 $10.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2002-0978
APPLICANT/CONTACT PERSON SHEA JOAN L
ADDRESS/PHONE 137 ELM STREET (413)584-5008 Q
PROPERTY LOCATION 137 ELM ST
MAP 3113 PARCEL 167 001 ZONE URB HD
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building-Permit Filled out
Fee Paid
T_ypeof Construction• REMOVE INGROUND POOL*FILL -
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
Signature of Building Officia Da e
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.
__�::..v�t ... .Kf�,w. ,:,'S=aa�risrst'.rc.n<.•...-•.:,�KN_ .. .. ...,.....
r"� pity of Northampton
__._.--Vul1ding Department C
212 Main Street
MAY i0� ate' Noom 100
' Nollthartipton, MA 01060
phone 4153'587 j1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.SECTION 1 -SITE INFORMATION
1.1 Property Address: c
This sectiors�to be tom yet
b'
'Ma
SECTION 2-PROPERTY OWNERS HIP/AUTH6AVE' DAGENT
2.1 Owner of Record:
J_oe-n Sh-'e-C 1.2o E Im 6�1 N t r etmr_>i-on
Name(Print) Current Mailing Address:
Telephone
jia�t(u!
re
2 2 Authorized Agent:
Elm S} - No ff hAmp a
Name(Print) Current Mailing Address:
Signature Telephone
SECTI6N.3 EST iMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use"Only
completed by permit applicant
(a) Building Permit"Fee
int
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 1 B10
This SectionFbr Official Use"Onl
Buildi"ng Permit dumber:' Date issued-
_-
nature:
Building'Commissione=/lnspector of:Birldings
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 V 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 V 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':f
C. Do any signs exist on the property? YES NO V
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:
i
SECTtONtS DESCRIPi10 'iR`POSEDWW #i2FC _ c be til 'lei
VU wnM3YiYY gAnd m 9 .R,,,,M1I h3# �' t'4
*RPM
New House ❑ Addition ❑ Replacement Windows Alteration(s)e Roofing ❑
Or Doors 0 1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: UoaIPZ10_1 l�Y � � 'I►� /r/ /J
Alteration of existing bedroom Yesy _No Adding new bedroom Yes V No t
Attached Narrative 0 Renovating unfinished basement Yes V No
Plans Attached Roll 0• Sheet 0
fiNeMof s"'e.= 1% dflifibb f
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 construcnn. 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? YesNo. 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
1. Septic Tank City Sewer Private well City water Supply
SEC ON 7a OWNEMAQT O,FftZA1•!ON T�.56E Ot)N!P{I TEt W,I EN
>t?YVNI�RSAOENT OtC41V"CRACIORAPPLtESrt 0R 6U1�DING:PERhA�T
1, �G C'r) e�'__ as Owner of the subject property
hereby authorize V—! C�{rc Sh 9 CCA, to act on
my behalf, in all matters relative to work authorized by this building permit application.
ao
Signature of Owner Dated
I, C (?qas 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
SignatuTe of Owner/Agent �J Date
,.;.,.;,i:rssi�'4Y'.'}+.. .-.c.:sYF7�r�+n.r rc• ... _... ... } ... .. ....,,.....,..�..........
c
fS�ECT�O 8CONSTRUCTION SERVICES �
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
v. me n r Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1, WORKERS' COMPENSATION INSURANGE.AFFIdAVIT(KG.-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...... ❑
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 10813.5.1.
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 hgme 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 Massac usetts General Laws Annotated.
Homeowner Signature
` ¢-�1tAMP�O
.�O
8 � �:AS4AC}I IISttt4
DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WOM LEER'S COMPENSATION INSURANCE AFr'MAVTT
(licensee/permittee)
with a principal place of business/residence at:
(phone#) ''if' tS
(st MWci,ty/stafehip)
do hereby certify, under the pains and penalties of perjury, that:
xI am an employer providing the Mowing worker's compensation coverage for my
employees working on this fob:
(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:
(Nome of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/PoUcy Number) (Expiration Date)
(Name of Con.tractor) (Insztrance Company/PoEcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(abatis additioml shoot ifneo=L y to include information pertaining to all oxt.. n)
( ) 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 while homeowneta wbo,,,play pc==to do msj„�construction or repair vvrk w a dwelling of
not more than throe units in which the homoowncr resides or on the grounds apptutenant th=w arc not gcocralty oo=de cd to be
cmploy,rz incl the worker's compc=tiom Act(GL152 m 1(5)�application by a homeowner for a Uccasc or perm may evidence the
]egai status of an omployer under the Workeez Compomation AOL
I undentAUd that a copy of this statemOA may be forwarded to the D,partmoot of Indztsiriel Amid-n&Office of imurwoa for the
covmge verification and that failure to wall,coverago uod-soctioa 25A of MGL IM can lead to the iaV t oa of criminal penalties
ooaustx:t of a fine of up to S 1,500.00 md/or of up to one year and civil pemttia in the form of a Stop Work Order and a
firm of 5100.00 a day agninsi tree
For dcpat na W use only
0�—or4- �I� �?�- Permit Number
Mao Lot#
61FMatftJ of7.i�r