23A-277 (5) 6 MAPLE ST BP-2001-0686
cls a: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-277 CITY OF NORTHAMPTON
Lot:-001
Permit; Building
CaLge ors:wormy BUILDING PERMIT
Permit# BP-2001-0686
Project# J5-2001-1255
Est. Cost:$3500.00
Fec:S25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Claus: Contractor: License:
Usc Group;
Lot Siza(sa, R.): 6490.44 Owner: DELIS MICHELLE
Zoning; URB Applicant: DILTS MICHELLE
AT: 6 MAPLE ST
Applicant Address: Phone: Insurance:
6 MAPLE ST (413) 586-6971 ()
FLORENCEMA01062 ISSUED ON:2/13/01 0:00:00
TO PERFORM THE FOLLOWING WORIC STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector 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: (I�1: 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 2/13/01 0:00:00 I $25.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patlllo
City of 1U?UPI*II
Room 100 -
Northampton, MA 01060 t ' '' (Sm •r-� ` ` `°'"'* ':
phone 413587-1240 Fax 413.587.1272 "` ""� ,. ' "`"�"•`�
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: fFhle a ,0,0eiedh)TifftBd
1 inAP(F cT/FFAT Umi ,
49 FL t t- c F ii.A
SECTION 2• PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
Mic NE-u.E, S OwrS to MAPLE 5T FLoe&.Nc
Name(Print) Current Mailing Address:
eaS � [{i i-5Ste -69-1 /
�C.tA-IX-�'-z— `) '..t-u�.ra Telephone
Signature
2.2 Authorized Aeent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
corn leted by permit applicant
1. Building/REMOdc;} 3 SO (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 =(1 + 2 +3 +4+ 5) Check Number
This S. ioi fficial Use Only
Building Permit Number: • . Date.Issued:
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 by
Building Department
Lot Size . Iy 9 Ptak.
Frontage 50 P4
Setbacks Front
Side L: R: L: R:
Rear
Building Height 2 sira+lt-
Bldg. Square Footage
I,y2W Sif4
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Specialpe' Permit/Variance/Finding ever been issued for/on the site?
Sp
NO c0 DON'T KNOW 1/ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registr 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 ✓ DONT 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 here any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
•
ECTION 5-DESCRIPTION OF PROPOSED WORK(checkall applicable) 1 ,
New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing V
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
/
Brief Description of Proposed Work: l U 4' l _ r
Alteration of existing bedroom Yes `-/No Adding new bedroom Yes L) No /
Attached Narrative U Renovating unfinished basement Yes ‘/ No
Plans Attached Roll u - Sheet U
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?
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
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
OWNERSEaka
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Y Ca - �1n n / , as Owner of the subject property
hereby authorize Je 3 ' /r) i/CACtE S Alf A-2 IDNC. to act on
my behalf, in all matters relative to work authorized by this building permit applic ion.
,Y h,Uck&fl-ii_ Th D.tL*s 2491,bl
Signature off1 OwnerDate
pp�� Date
I, )( LUckJ&Q.. 3 �-F:S , 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.
ribSigned under the pains and penalties of perjury.
q/ MICNEL(.£ 5 -DILT5
Print Name
X LU S -o.a9Js 2-41)6 ,
Signature of Owner/Agent Date
y§ECTION 8-CONSTRUCTION SERVICES
4.1 Licensed Construction Supervisor: O Not Applicable 0
Name of License Holder : / d" J yy� /C15 /// 4C EQ S /ch.., /A+6-
✓ License Number
a 3b 50,9 TJX 5T/fKrT Atotrd N4.np7 /fl45
Address Expiration Date
V/3 -- "'co
nature Telephone
- fT,-_i r ss.v.n,`) t c. . �..r' '1' 'rs: t..., ;lSs A'-Y`.. Not Applicable ❑
.s71-1.
Company Name Registration Number
Address Expiration Date
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.
igned Affidavit Attached Yes 6dlNo 0
s_Fr eL rs < �a� it 15 i�il
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.
e ,
Homeowner Signature t Cn�.OD o- 5 'ls--"-a-er-
¢ZHAAfPrC
0
„ ? 9 Uifg of rrrfltantgtnir ��
w�
t= . .r'3e $xsaxieifzsars' -f-
e .tri
DEPARTMENT OP BUILDING INSPECTIONS 't
212 Main Street ' Municipal Building
Northampton, Mass. 01060 "
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
d �//, :7
with a principal place of business/residence at
7 - - honest} 4'rSStj/6.o
(streetraty/nait/Mp)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job'
i`'
-
tX (Insurance Company) (Policy Number) (Expiration Date)
ii'i (dcI am a sole proprietor, general contractor or homeowner (circle one) and have hired
tithe contractors listed below who have the following worker's compensation policies:
T
'(Name of Contractor) a ranee Cont • /Policy Number) (Evpimtiou Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(wee additives'w«<if necif nemamarysry to Orme itrution pwiaing to ear cecina/co)
(+) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE:Oa be aware tkat wets A mcorvms t employ pCoa+m&mamensatt manu¢icn a/Vat•••12011 11.11•1•3115k of
vat more than thio units a With the hamm atmemaid=or m the grwm&wpm-trout thereto aro not genaalrymmide atto be
employers°mkathe wu,ku'a ctawcnsnim Act(OL152 n1(5)),mytintioa by•hameowoa fore 4wss a pant may cvidr"^'Me
lewd status Druz mepfoy,r under the Werkah 0oa pmuion Act
I und¢ssnd that tcopy GM*rtarmme any be foaw.zded wile lkpmmem neraeaw;a nmGnts'Moo ofivurme tanks
wvnage vaifatiwasci that failure to saute oovaage=dm-satin.25A of Mate 152 Ms Id to the*maims ofaimizst paunia
eoasiaitg afa fere of up m S1}00.00•uYa imryiw®e5 of up to omyam and civil prmhle w the form oft Stop wok Orde and s - ..
Sm of S100.00 a May sgpiat mu
For hpntmasl arae 0ty
Permit Number
✓�
MaLot d
of Licensenteermittee Lhte Pd