23A-008 (5) ,z0,-4A-4,;,;;Nflg PAflK st'.- BP-2002-0498
GIS s: COMMONWEALTH OF MASSACHUSETTS
0131ock:23A-oo$'''77 CITY OF NORTHAMPTON
Lot:-001
Permit: Building ��/�
Category: ALTERATION BUILDING PERMIT
Permit it BP-20020498
Project# JS-19991477
Est.Cost: $9000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Richard Labombard 055340
Lot Size(sq. ft.): 12458.16 Owner: BOTHWELL SAMUEL P JR
Zonine: URB Applicant: RICHARD R LABOMBARD
AT: 38 PARK ST
Applicant Address: Phone: Insurance:
119 Park Street (413) 527-7427
EASTHAMPTON MA01027 ISSUED ON:II/9/01 0:00:00
TO PERFORM THE FOLLOWING WORKINSTALL 3 NEW WINDOWS, MOVE BATH
WALL, SHEETROCK LIVING ROOM & DEN
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 11/9/01 0:00:00 2909 $50.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
•
City of Northampton
Building Department fcro'
D E C IEO V 2 ain Street
,
LS i t ,{, 0. ,100
Nor ton, MA 01060 _
1 w ph§nt}13.61240 Fax 413.587.1272 eP
e
A. IrH65rRUC ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
p p
Ma- egrwcr-
Zone a .t"r' e .
Elm Sti`6 s t
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
DAv'o 6 vtkL Fy 3r '✓ne, sr- , ir-Yv,ce3tic E
e(Priat) Current�yM_a�ng zAddrgs :
ry - ' •tom®--'—`— Telephone Y 6
S nature
2.2 Authorized Agent: /
gcy yes) LA/)OMDard ,2)'. // PAS Si t957:4 fi2/TD/1-/ o/4(7
Na (Print) , Current Mailing Address:
l q S 7 79)-7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building O5 0 C7�) (a) Building Permit Fee
2. Electrical -CJ (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) 7OOd. OQ Check Number
This Section For Official Use Only
Building Permit,Number. EP-zco2_-e' .� Date Issued: ?1
n 4
Building Commissioner/Inspector of Buildings
•
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:
SEOTIo , r i'jfia .. R gra- W'OR crr�aauLczb
r . ra.cek�cn
New House 0 Addition 0 Replacement Windows Alteration(s) l!Y Roofing ❑
Or Doors ® --
li Accessory Bldg. 0 Demolition❑ New Signs [ I Decks [ ] Siding[ ]', 'Other[ ]
Brief Description of Proposed Work: Z/I/S/?JLL 3 d/R✓ LUNAdi✓S/7a KE //,// /N9� 1Lz�iej•v//LL LIP. /07,
- DEN.
Alteration of existing bedroom Yes '"----No Adding new bedroom Yes ✓ No
Attached Narrative❑ Renovating unfinished basement Yes -' No
Plans Attached Roll O. Sheet 0
OalfanliMiMigarndliiitiOhattiar§tilltaidirg hi ?anwI tl,#hvffbil :
a Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms L
c. Is there a garage attached? NO
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
I. Method of heating? 5m Fireplaces or Woodstoves d 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
7
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 dRCONTRACTOR.APPLIES FOR:BUILDING PERMIT
I, , as Owner of the subject property
hereby authorize to act on
myppehalf, in all matters relative to work authorized by this building permit application
+t
I' Gv 4�x �
i/�(/DI
Sign. ure of Owner Da e
fic-"Med 14_4240, , as 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.
/ icM49& Ziiiir, 14:1
Print Nar- gy " - r
/a/3/ a/
Signature of Owner/Agr Date
•
StE 4:6WieOOitusON sERJIIC'E.S•
8.1 Licensed Construction Supervisor: / - ,// -rte Not Applicable ❑`/
Name of License Holder : it L 4* ig//m/afro `STP osc3 t a
License umb r
�r y
Mek sT 6957/Igny 4/ a/427 /O , ),
Add ¢v; ,> i Expiration Date
liderlIS/2 -5)-7 2/07
Signature Telephone
Altk 7ti't takli itr it• x 'k'± Not Applicable ❑
/U , 7A-e,/
Company Name RegistraY n Number
eaiA
Address Expiration ate
Telephone
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
❑
phi •le`a.'p a i...
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 108.3.5.1.
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
B�4!_" (attar of 'at•#f1antptan -• Y
techs B .6.isesuknerl.• _
DEPARTMENT OF BUILDING INSPECTIONS 4 a
212 Main Street " Municipal Building
Northampton, Mass. 01060
/, Q WORKER'S COMPENSATION INSURA.NCL AFFIDAVIT
I, �1� ' ' Oflkd rn
(licecsalperovttee) _...
with a
principal place of business/residence at:
....J/ t /en sr. & /heLa -1 /l /J/tD,l4one#) (493) c 77 ��7
(sDurtcity/staWno
do hereby certify, under the pains and penalties of perjury, rhar.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Due)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Nome of Contractor) (Insurance Company/Policy Number) CExpimtioa Date)
(Name of Commerce) (Insurance Company/Policy Nu trier) (Expiration Daze)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach aMitiosa isect iFn..,..,,y to ode estrm.tioo vaaiainy a au a r,am„)
(e ram a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE?tease be aware locatable hcowwotn%Motcnploy vnuao to do raitadtc¢,.wx,mrmueid tv rrar work on x duttidng of
not aeon than tone train in which tbe bastootataat reale x cc the pratdltsgavteoerEPvecdo arc ea gully wmideel to be
mgtoyas uodor the wttn cacadttatadien Ac (9L151F t(5)),application by a homes to fare 4aate tie petmamay eMetoc the
legal Aldus of as cop toyer uodxrtu Wohah Comyamation A .
I underrated that a copy of Ca ahlamt may be forwarded to do Dynode.of iS,e,i.1 Aoddf Oboe of wnau,w f da
oowng<vaiticAioa add Mad&iiuc toted=°won *wadasedioc 2$AafMGL 152 can ksdto Naimpomismofaimioai 9=1k-rex
cmiistiugore.floc'of up to St}00.en cd+erwryooamcrtofup to ora year and civil tumhia is the face of Moo Wcaieeoda soda
fno 44'3100.00 a day against aoto
4/2f1,2eir
/ PerFa atilt umber ary
Lot
Signature of Li , aermittee Date tb,.
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