23A-004 (4) BP-2002-0479
can COMMONWEALTH OF MASSACHUSETTS
bttIock:23A-004 CITY OF NORTHAMPTON
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002-0479
Project# JS-20020724
Est. Cost: $2300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Jack Walton Construction 107687
Lot Size(sq. ft.): 8973.36 Owner: MODESTOW JOHN E&NANNETTE B
Zoning: URB Applicant: Jack Walton Construction
AT: 25 MEADOW ST
Applicant Address: Phone: Insurance:
130 County Road (413) 667-3358
HUNTINGTONMA01050 9727 ISSUED ON:II/1/01 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 11/I/010:00:00 2082 $25.00
212 Main Street, Phone(413)587-124Q Fax: (413)587-1272
Building Commissioner-Anthony Patillo
lisi to , ate•. t r
K a _ s:�- �: ���t�.f Northampton S = �r �y-
F aRra 41.f Northampton
Department C e ,A ,4 t.
1 �i - • Main Street Se-AF,- - c...,. $;.-
t 1 oom 100 Wate / , A(` ""
...fin, „ .r n pton, MA 01060 7�o`ySett
% i� t. * :7-1240 Fax 413587-1272 P Ste Pla "•d -;.:1.:-1:.-;-;:-,,,,k;'-/4.4.-..:.:
Other Specyfy '1
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
.This section to be completed by office `.
1.1 Property Address:
Z5 MFAbcr/J 17.- Map Lot Una
yN`
' TLo1RE-tee MASS • 0 6
162 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
I
2.1 Owner of Record:
�ff4
Za\i 2S ItiFh`y; ST. hcC �tJC� �u1 . 0(C6�
Name(Pr nt) I nl 4� Current Mai lino Address'
X1.
) / � � hane 61ti:
phore
Signature
2.2 Authorized Agent:
--AC k w/A ca-04 /70 &Q....fry i24. *!J 77,4 /, ,NA, o/ose
Name(Print) Current Mailing Address:
.,4 Vl),,h 413 - 66 - 335
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
Re-ic-FF�6L-RR&,E completed by permit applicant
1 Building 1/21. -r 23o° 00 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4- Mechanical (HVAC)
5- Fire Protection
6. Total t (1 + 2 + 3 +4 + 5) t'23d0. 0 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Dates.
•
r
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)
li of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO j< 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 )C 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 x,
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:
SECTION"5- DESCRIPTIONiOF:PROPOSED1WORKKcheckall applicable)
New House 0 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing �Q
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ I Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: SKIP LAYM5 ,Jf hdi:Fr�-C{� < v574CL
Alteration of existing bedroom Yes XI No Adding new bedroom Yes /S' No Ori
Attached Narrative ❑ Renovating unfinished basement Yes f"y^ No EMACA
Plans Attached Roll D- Sheet C
tia:-If NOW hONsO-affear'add itionTo a"xistinR-hcius[nP.'coriiDlete#he fol[oWiii:
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
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
I, --TUN/9 t . SAC, ' S'iov''3 , as Owner of the subject proper'.
hereby authorize' n - I ^�-fly vv4c,ti4 to act
my behalf, i ' II t s�ela h. I authorized by this building permit application.
�� AI �, 70/31/)1
Signature off70 • Date
I. drlCk_ yvi4L27t4 , 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.
---.MAC lc w/4C.-TOJ
Print Name
rill u /o 31/a/
Signature of Owner/Agent D to
•
•
Q,w • 0 S:RUG'TIONS RV>C, 5.: , ..
8.1 Licensed Construction Supervisor: Not Applicable ElName of License Holder: rc-i-ACK . ,A(-r)/ n O Z`J pJ
License Number
130 Coxr4T`( rPD . tIJ:4Tb^C67aaj4 OIO3D / X5/3
Address l Expiration to
-<7;24 i ti/ 7�x , 413 667 37 96
Signature Telephone
Not Applicable ❑
,�, f�)
Company Name Registration Number
l3ocn 'TY '/ b. HJ C-Zdb2 kw1of0Sa totle23
Address Expirati n D to
Telephone
- 'SECTION 10 WORKERS' CQMPENSATION INSURANCESFFIDAVIT.(M.G.L. c.152,§25C(6)).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidao-
will result in the denial of the issuancpg of the building permit.
Signed Affidavit Attached Yes 41 No 0
MATO tiYclITTAD
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2)families
and to allow such homeowner o 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"shalt 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 -
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BAS 'Al (gag of dlrrftj&tttpfou 1 =*-$
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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building 1�T �
Northampton, Mass. 01060 (
WORICER'S COMPENSATION INSURANCE AlinDAVIT
I, -at' W4c"r
(ic permitI«) •
with a principal plan of business/residence at:
1-3a axiAfi ( go- N,r,.1Trs t of PO otO ) _(phone#)._66733
(street/city/statthip)
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 working on this job:
(Insurance Company) (Policy Number) (E•xpim&on 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 Number) (Expiration Date)
ii
(Name of Contractor) (Insarancc Company/Policy Number) (Expiration Date)
(Name of Contractor) ..... (Insurance Company/Policy Nurnhtr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aunt e44.0444 ehcet ifM'rn•y w ioehr6:iokwueion pwinins w At wonaeon)
I am a sole proprietor and have no one working for me.
///("' -) I am a home owner performing all the work myself.
NOTE:pure be aware[Int vtito lsecences-acsa wtescaploypasom Le M®'enennws. mW<ueion or repair workers a dwelling of
not mac than three un1s in whihtbe bonwnnc resides or on the ground,aypmtem*theto us not geoernIty amideel to In
eaployaa uMa th wwka4 o»Wenseticu Au(GLI52441(5)),applicuien by a bomwmsi fare Homc ccperme may evidence 160
Itad stains oras employ«under tn.Workota 0.4y.a4tioa Az
1 uadeusaddw a copy arwia menusa may be lawwd.d to the Ayenemtnflodu nat,Asudentfgfiico M3m.ma teethe
coverage vnifiottion andthsttiiee to sawn coverage rods section 2SANMOL i5]caolaMU t6+impatiliao of minima penance
owtiAmg ofa fine neupms 1500.00 nWccimwisoanxnt of up to axy<r sad civil penMM«othe foam era Sbp W01&O1d0.44a
540(3(00.00 t day again+(mc.
�, //� For b4nt t'sa°adY
'Iv-4 •%iig Permit Ntmhet -_
Map.Y Lot#
, . . Sigma-tura of Lkcusee/permittee Date t