07-004 (8) 516 NORTH FARMS RD BP-2003-0954
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mav:Block:07-004 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cat eeorrREPLACEMENT DOOR BUILDING PERMIT
Permit# BP-2003-0954
Project# JS-2003-1542
Est. Cost:$2247.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: contractor: License:
Un Group: James Locke 100209
Lot Size(sn.ft.): 60548.40 Owner: SP .RRY 'MARL-S R&CLAUDIA S
Zoping:RR Applicant: James Locke
AT: 516 NORTH FARMS RD
Applicant Address: Phone: Insurance:
26 South Street (413) 268-9323,_.. Workers
Compensation
WILLIAMSBURGMA01096-9726 ISSUED ON:5/6/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE FRONT DOOR & REPLCE CHMINEY TOP
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 REGULATION&
Certificate of Occupancy Signature:
FeeTvpe: Receipt No: Date Paid: Cheek No: Amount:
Building 5/6/03 0:00:00 3814 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
Citybf Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
rt -- 212 Main Street Sewer/Septic Availability
Room 100 water/Well Availability
MAY - 6 2003 Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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 Property Atltlress�'./ rn s��l ��f� This section to be completed by office
z C. - 12�P/ /`m`�-ti / "0 , Map Lot Unit
f _9/2 d t�1 d' A 02 DMZ Zone Overlay District
W Y�'���/ 'C/ �"vd'r Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2/eline Q altuDASf% ' 516 /U, ,%e#-< /2/) .
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
1/4/4itj c / ✓i. 2h Set'm 5-T, CU/u/, ius dge
SName(Print) Current Mailing Address'.
tcGGJ zee 9�z 3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant p
1. Building fee 'Oen- (a) Building Permit Fee
/26/ CN/ tv(l/
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) "1Z2-q7, Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:Signature:
Building 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 filled in b>
Building Department
Lot Size
Frontage erS
Setbacks Front //tl C' I.:
tl
Side L: R: h: R.
Rear
Building Height
Bldg, Square Footage
Open Space Footage
(Lot area minus bldg&paced
parking)
k of Parking Spaces
Fill:
(volume.@ Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW ✓ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT 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 1/
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:
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) CS' Rooting El
Or Doors ❑
Accessory Bldg. 0 Demolition❑ New Signs [ I Decks [ ] Siding ] Other[ ]
Brief Description of Proposed ` t�,),(
Work FeD e//» elellAti✓i P), _ 12-4PcdtG45, FMC% ODCA- t
s/gt cah"Ce
Alteration of existing bedroom Yes td--No Adding new bedroom Yes &L No
Attached Narrative Renovating unfinished basement Yes i/No
Plans Attached Rog -Sheet
6a. If New house and or addition to existing housing,complete the following.
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?
e. Proposed Square footage of new construction. Dimensions
e. Number of stories,
f Method of heating? Fireplaces or Woodstoves Number of each
g- Enemy Conservation Compliance. Mascheok Energy Compliance form attached?
h. Type of construction
i Is construction within 100 fof 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 CONTRACTORNAPPLIES FOR BUILDING PERMIT
I, L LAI) D I3m .Pf q ( ,as Owner of the subject
property ._.
hereby authorize c///4 Lvtske- t av a.- Laic-t e_ e 04.otee
to act on my b- .If in all mai-rs relative to we k authorized by this building permit application.
i7tt 1
Signature of Owner
,�.,r �� gyp Dale
w""�f 04fer '�' as /AuUiorized
Agent here declare that the statements and information on the foregoing application are true and ar pirate,to the best of my knowledge
and belief
Signed under the pains and penalties of perjury.
J ti
1-Oat—
print Name
Signature of - /Agen i Date
SECTION 8-CONSTRUCTION SERVICES 1
8.1 Licensed Construction Supervisor:
e Not Applicable ❑
Name of License Holder /A
i 1 t5 rter/y4 - bb/ptZ-
License Number
2 sc7,7-71 5-r, km-emzws-56#9e.e /z - 5-- D3
Address / Expiration Date
Signatu Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
-n-v6-r ia;v 4- .tockt— 76 0 ze 9
Company Name Registration Number
7 , Svv/ i sr, Witt firs ooze-- (9 -/z -CV
Address Expiration Date
Telephone Zb€—e3 2
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 n - No 0
11. - i , e Owner Exem I tion
The current exempti . for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(21 families
and to allots such homeswner to engage an individual for hire who does not possess a license,provided that the owner acts
as su I ervisor.CMR 780 ixth Edition Section 108.3.5.1.
Definition of Homeowner: s son(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 t •. family dwelling,attached or detached structures accessory to such use and/or farm
structures.A i erson who construe - ore than one home in a two- ear ieriod shall not be considered a homeowner.
Such`homeowner"shall submit to the : ilding Official,on a form acceptable to the Building Official that he/she shall be
res I onsible for all such work erformed . der the buildim ermit.
As acting Construction Supervisor your press ce on the job site will he required from time to time,during and upon
completion of the work for which this permit is is .ed.
Also he advised that with reference to Chapter 152(• ¢kers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Mas chusetts 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 otMassachusetts General Laws Annotated.
Homeowner Signature
Y1tAHPt
bo4t,w ,moogarff�tinr{]tau •
f A•
Bg! 6 �r.n..rkl • lite'
Ails Ap!
DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSUILINCE AFFIDAVIT
&UR/G N 00(660 1/2A
(lrx,cerlp rmi )
with a principal place of business/residence at:
2h Sov-it ,57 w/t&L42 6§3e :.I .(phone;:) 24e-P2-3
(stret/city/state'np)
do hereby certify, under the pains and penalties of perjury, that.
(6-)" l zit an employer providing the following wor'ker's compensation coverage for my
employees worhrig on this job:
/15-5D66:1-ieL led‘ 6( $b$_'_Z7 & / L/ /&)3
(tnturanc Company) (Ponce Numin[) (ExpinOon Dare)
) 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_
(Nurse of Contractor) (Insurance Company/Policy Number) (Expiration Date)
( of Cunt tenet-)
_.-., ` ick) 6nmrance Co Intnetiyincetteek : t . :et? ninentrtetou Date)
N,.ne of C(1:11k1CIOr) (t¢wranon CoupredyiPolisy N Imtr_r) l :oa Date)
(N-nu of Contractor) (Inslmacc Olem.._.y rye ae Nura'erl (tiouration Dare)
(enec 4 :el durst e iw.uei ineenernecing Win n ._a., . 1
) I cul el soic',el optietor and have no one working for ma
() I am a home owner performing all thework wysoif,
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