23A-011 (2) •
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BP-2003-0589
GIs it: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categorx: BUILDING PERMIT
Permits BP-2003-0589
Projects JS-2003-0966
Est.Cost: $,3835.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class;: contractor: License:
use Gronn__ Robert Thibodo 118441
Lot Size(sq.ft.): 11020.68 Owner: ISRUMPHOI2 FRANCES V
zoaiae:URS Applicant Robert Thibodo
AT: 30 PARK ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAM PTON MA01061 ISSUED ON:12118102 0:00:00
TO PERFORM THE FOLLOWINGWORK:STRIP & SHINGLE 2 PORCH ROOFS
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: 00: 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 12118102 0:00:00 1546 $25.00
212 Main Street,Phone(413)587-1240,Far(413)587.1272
Building Commissioner-Anthony Patillo
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City of Northampton S socffi
' Bulidng Department C!u /-:pet
- I : • 212 Main Street Se r/ d�sekt: , :oh.-
Room 100 Wa er/� e F .y 'et _ '
p M-2 Northampton, MA 01060 jiw Setso i`i e 1 1� �:�
phone-413-587-1240 Fax 413-587 1272 Pl"o /S4F:Pp}: � ,54
Ott er Spectfyr—.7-.-77:77- • • '- ,..
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address / This section to be completed by office
A �� nir
J� a,I. 1.-ef/s// '�[dteci;f/ Map Lot llnit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner oford / i
A2 l tent MO i ilS eV._rCSs.
c92,et ega mpFo�z
°�Sgne e�r�. v Col r y
2_2Authorized A ent: ��r � 33///
la To ephra=
I /.;///
Nair f)Ara ) / 7 ) / el,' riad ng :bJ3ess 4(55'o/
( 9$ // 793. 7754 V7735—NL-zf((JZ
,LLAnot33/ el h ,i
SECTION 3 _ESTIMATED CONSTRUCTION COSTS / o c
'aem Estimated Cost (Dollars) to he - Official Use Only
_ _ _ __completed dices-pi' applicant
,si Iding I MD Building °ermit Fee
Imo_
El _, _al tima3c, Total Cost of
n b ,.cnsi c '.,nn from (6)
I3 ing Building Permit Fee
14 Vecnanica, IVAC.
r
r Fin Protector
- (1 : 7 + 11 J) L CIeck ur ,er
This Section For Official Use Only
Building Permit Number Date Issued:
Signature'.
LBuilding 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 filed in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L'. R:
Rear
Building Height
Bldg. Square Footage I % ..........
Open Space Footage
(lot area minus bldg&paved
.arkin_
g of Parkins 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 ,, 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: ....__
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SECTION S-DESCRIPTIONtOF.PROPOSED WORK(check all epnlicabte) `
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofin
Or Doors O
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
9w
Brief Description of Proposed work,._ :. /L' fr — ?fa/Ad
4
Alteratron of Narrative
it bedroom_ Yes • _ No Reding new bedroom Yes No
Attachede❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet 0
6a01f?NeWTh6Useindiori'adciition to'existing 1housing, completethe fUIIbWifig:
- Use of building One Family_,. - we Fared[= _Other
b. Number of rooms in each family unit: Number of Bathrooms -
c Is there a garage attached?
_. 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. -,_ N.ascheck Energy Compliance form attached? --_
.h. Type of construction
i. Is construction within 100 ftof wetlands' Yes No. is construction within 100 yr. Iloodptam Yes to
r 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
/I/C ES �hp�( C{ M( LL __... , as Owner of the subject property
hereby authorize OU p b (241. (1.F 6-- _ _- to as' :-
my
oftwrier
in all ma t rs relative to wort autho d br this r tr Id rg permit application.
/LnG41-'44.M1316 �
gd Owner r9ate
� d 7/4i/0 ,-ds m/ utl nnecm Agent
hereby re are that the Statements and information on the foregoing application arc true and accurateto the bast of my
knowledge and belief.
Signed on he pima and ie.. if perjury
Prinf
mer / - 0
2r
Signa .re of ematrrage tt �L agg''-/2
nae ,
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SECTION'S-.CONSTRUCTION SERVICES
8.1 Licensed Construction Suprviso / / Not Applicable ❑
Name of License Holder : a6
rr
License Number
Address 422 // 7 7 Expiration C/
Signature Telephoto
k T/ f, 4
9f'RFete fed 1lbineslmprevem'e`nt Contractor „'�^x a tW,f,.( ,'t aLtteFisn't; Not Applicable ❑
Company Na /p � ���r
1c _ / �� / ,� /�J egiFn Number
Address ,//�� /71.-2-7.11-1-11.
//j'�j —/e Expiration ate
//f77K<' 2(.27 /'`-1..ho 77/// 6'3
SECTION
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 affidavl;
will result in the denial of the issuance of be building permit.
Signed Affidavit Attached Yes No ❑
utft' ,ne5 eti pt1on
The current exemption for`homeowners”was extended to include Owner-occupied Dwellings of one(I) 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 108.35.1.
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 hr 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 Dead])of the Massachusetts General Laws Annotated,you may be liable for person
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 Toning Lases and State of Massachusetts General Laws Annotated.
Homeowner Signature
/O mhp,,O
7,,,-,
Ccs
�A a (rite- of Northampton m pton �y
' 7 7 ''t eat A x8 ,Sixoaxc¢ncdb' '
DEPARTMENT OP BUILDING INSPECTIONS ti.
€ ;
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORX91S COMPENSATION NSCR2ANCE A11,11DAVPI
1, agf - i c
tic. xrr ntiorx)
with a principal place of busmesshesidence: AC
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(phone tl
{=r:cttoit 'saErinp)
do hereby certify, under the pains and penalties of pegwy, that
O I am an employer providing the following worker's compensation coverage for my
employees woridng on this job'
(Lamson Company) (Paint Number) (Expiration Date)
ant 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,Corrr)nnyiPotic-Nurnbcr) (Expiration Date)
(Name of Contratint) Closurancit Como anwPoliq taumtNr) {Lxpirscon Date)
.
(Name of ConlMotor) (Icer neZ C. ni> ol.^_.'Nemec/ Ciiihrinitiron Date)
Entine of Conlncior) (Insurance Cour::nyiPobcv Sumba) (Expiration Date)
p.ar anhido,ni Asst annstriry tc.iry.iu&n:o-tncial vmlcr,-dl 7...a,e.,nl
O I Imr a sole proprietor and have no one working for ane.
O I ant a home owner performing all the work myself,
NOTE.phzaxt<c,.a:cex:.e.-to&. ,wxxn roc_-icy—,i m m»_.cws.a -+ra,Yr Cr gaiz 3e,,: p,of
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..k >i<
catplo)aau4rn nuns,m.'cm
ti) Act(C a LI 52 I(5)), iontry a 6ccamwsr far a Ettnc cc rn
+ per rtY nitcat the
lasil papas of aa ac�lova under to W'uktei.Coerym.tiaa Aar
I uvd-rn.end th.t i copy of Uv n..,,,,,, =Ay ba forwac-d i to th,arch-rayon ser+ureic Madam OfLcc eL 4_:axws for th
covagt vcrifclim M Oat t4ure torvut cottage it y„ctio_23Aofit(OI.I52 an lad to Ve-elvirv++ea aratbaxf rtatkiti
+aningoa tent Of up ta 3 I.500_00 armx eye[tot n3 to c+c)v-udwvii paulua in tut ftnn of n Stop Wca Oede and
Eno of31.0000 a day IFAIIMrc
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Pc-m.t NUMbe$
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