31A-115 (4) •
38 VERNON ST BP-2000-1 137
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mari:Block: 31A- 115 CITY OF NORTHAMPTON
*temsrot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-1 137
Project# JS-2000-201 6
Est.Cost: $800.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL KULIS 124962
Lot Size(sq.ft.): 1 0628.64 Owner: MISCH PHYLLIS A
Zoning:URB • Applicant: MICHAEL KULIS
AT: 38 VERNON ST
Applicant Address: Phone: Insurance:
10 EAST ST (413) 584-2358
EASTHAM PTO N M AO 1027 ISSUED ON:6/1 S/00 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR COVERING ON FRONT PORCH &
INSTALL ROLL ROOFING ON PORCH
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
`nspector 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:
"luilding 6/15/00 0:00:00 113 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
v
I •
1 4
1 Department use only
• .. I ity of Northampton Status of Permit:
:uilding Department Curb Cut/Driveway Permit -
6 2 s,r` 212 Main Street Sewer/Septic Availability
,,\6\:1JUN ' Room 100 Water/Well Availability
pE ��g,„INI.*ItE 06 *or'! ampton, MA 01060 Two Sets of Structural Plans_ _
101101-4-iiC o o'''..1 - • -587-1240 Fax 413-587-1272 (Plot/Site Plans
Other Specify—
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Pro ort Addre s: �/ This section to be completed by office
/ 3ern OY1 -)11- Map 3I Lot // Unit
4((;./\t/PI-77e,-"\ Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i 2
Name(t' t) Current Mailing Address:
-0(.4.; f/a�4- ` `• Telephone
Signature
2.2 Authorized Agent:
-)/v1,74,e, el, )ci,,h• „-',_-_,___- /,, - ,
'5' . Cc-4 f_. e,...,4/4,79, ,9/7,>,,,,,,
Name( rint) 11)(,.,„1._
Current Mailing Address:
Sig Telephone
Tele hone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
ya 1. Building (a) Building Permit Fee
�' P p
6-0
2. Electrical (b) Estimated Total Cost of r�,--E0;''
Ccnstruction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3+4+ 5) Check Number `/.3 /75-0
This Section For Official Use Only
Building Permit Number: P -1 Date Issued:_
Signature:
Building Commissioner/Inspector of Buildings Date
f
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 s. DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contairi 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 anysigns 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:
r
I -4.
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 . Roofing 0
Or Doors ❑ ,, ( 1i ��``tt
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: I l ''"' , "''^ f"-y fir?- Ct / e.‘,---"3-71 .
Alteration of existing bedroom Yes No Adding new bedroom Yes No �.. `
Attached Narrative❑ Renovating unfinished basement Yes No PIrc
Plans Attached Roll - Sheet 0
6a. If New house and or addition to existing housing. complete the following
a. Use of building : One Family Two Family/2 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. MascheckscEnergy Compliance,jform attached?
h. Type of construction /1:' Q'Y"' 1 ''J -f '/ 'O"t? 1 /
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 PERMIT
�� l
ri '/ L h as Owner of the subject property
hereby aut rize to act on
my beha , in all matters relative to work authorized by this building permit application.
L.A....41 „ >(.,
Signature of O vner Date
I
' , as Owner/Authorized Agent
hereby d Clare that the stat ents 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.
>( A 1 .(9 2-7 l' ti 1-, Ls'
Print Name
G - 67 - zoo0
Signature of Owner/Agent Date
s ;
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
!
67, (///7/d
Address Expiration Date
•
Sign3fure Tele hone
P
9. Registered Home Improyemen C ntracto.- Not Applicable 0
Comp Name Registratio Num, er
/ ----ca-c4 ' j 7 (2/
AddressExpiration Date
Telephone
C 4'7 68'
�
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 ❑ No ❑
11. - Home Owner Exemption
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 d Local/Zoning Laws and State of Massachusetts General Laws Annotated.
7/iHomeowner Signature
U
N
> S'
f
•
s:c It1VAf pi,
+� �-
,�,,` tic (Gi Of NOrili%1111114011 ) .-=litsd fler..� `M y1aJ 6A rhrtE[II6 1
T r �* •
d DEPARTMENT OP BUILDING INSPECTIONS
rt
212 Main Street ' Municipal Building
Northampton, Mass. 01O6O irr''•-
WORKER'S COMPENSATION INSURANCE AFFI.DAVTT
X _ ' S.,.."/. _____Fit .€9,:e")...„ 41,742.09•••=8. r-
1, Le/S„c4e04.
Oice ucepertnittee)
with/a principal place of business/residence at:
_ ///Je--4 a f' J ' // .S (phone;=)- _5-S-- --5-3.01
(srr �t/city/sta.tef p)
do hereby certify, under the pains and penalties of perjury, thar
O I am an employer providing the following worker's compensation coverage for my
employees worming on this job: .
(Insurance Company) (Policy Number) (Expiration.Dale)
iiii ( ) 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 Numb:) __
(F_aptrauon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Ex-viration Date)
(Name of Contractor) (Insuranca Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(attach sddraec l bed if ceenssary to Maude info-t:iahon pertainins to.t1°occurors)
,k, I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pl ase be aware that wtr10 herneotsocrs wtio cnsploy pCsons to do m it tret1nx+ ccaxnsaioo Cr repair work on.dwelling of
not more thea thnoo twits io which the homenemer rmides or on the grounds apptutcr,a...therm)are o0t gene aky cocr4con to be
mploytan under the we kor'i am pion Act(GL152-cs 1(5)),supplication by a bomaowon fare borax or permrt Dozy evidence the
Iegat etaau of an employer under rho Worlcor'.Compensation 1.11:4-
,-
I understand that a copy of thistccxm mwpamcv
ay bo forwarded to tbo gaate of lnduerial Acci&asrs'Offioc of 4s;ur.noo for the
��'/r moovengc verification and that failure to seam coverage raider suction 25A of MOL 152 ton lead to the imposition of criminal penalties
conniving of a fine of tp to S1,500.00 and/or izr tisonmect of up to one year and cavil panPaa in tSe form of a Stop Work Order and a
fieri of 5100.00 a day against tot
. ,k, . For dap.rtm rJ use only
/� ` 1Permit Number`i y
Signa tu t of LiccnaJ
sPctauuoc Map'' Loi
• v'
•
•
S