23A-093 (14) 17 FAIRFIELD AVE BP-2000-0889
GIS it: COMMONWEALTH OF MASSACHUSETTS
4ap:Block:23A-093 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:routine BUILDING PERMIT
Permit# BP-2000-0889
Proect# JS-2000-1650
Est.Cost:$1200.00
Fee:$25-00 PERMISSION IS HEREBY GRANTED TO:
Const.Clasgj, Contractor: License:
Use Group:_ W M Brown 038426
Lot Size(sa,ft.): 13242.24 Owner: RTON J•BN T&LOUISE H
Zoning:URB Applicant: W M Brown
AT: 17 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
177 West St (413) 247-9937
WEST HATFIELDMA01 088 ISSUED ON:4/14/000:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring B.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
.00...Building 4/14/00 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Pati Ho
•
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 ;
phone 413-5871240 Fax 413.587.1272 '. � "' `' „i s ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property
rope[ty Address:
^JgT+his sactiYosp
UMti17 &J plod Map
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1
Owner of Record: q
gifoteam Print) Current Mailinaddress:
Telephone
Signature
7.2 Authoriz!ed�Aeent:
e?✓. M..TSns..'x. 177 .1(/wnt Si: J'4I ..Id, 1 /F a f�'
Name(Print) �/ Current Mailing Address:
‘,7021, -w( etux (fl) tiff"- 9737
Signature Telephone
SECTION 3 • ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building (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) .434a3 •oB Check Number /720This Section For Official Use Only
/el3uilding Permit Number: JPijib X9 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
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 vorDON'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:
oink
D. Are there any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
Allike
CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing wit
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Flft,cA Atari geC nuat ni10R..w. r" WAJ T".t& mad
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll L - Sheet L
ean.TaiP " )iraift* comDiet: ii2-Ar.11 tai fA�:
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
fig. 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
, 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.
Print Name
Signature of Owner/Ag t Date
JaECTION 8-CONSTRUCTION SERVICES
..1 licensed Construction Supervisor: Not Applicable 0
Name of License Holder: tAf, R( -aro W tU
License Number
1'1'/ hJeat,St - \.1J- hkatcieVd,MA o.r d .F.� O38yz6
Address Expiration Date
a
II at, .,. ,. *If) I_. _ — " ;a< .'f— W- 6'.t
Signature Telephone
"" ` `
;AL- ii fr;, R., ,�, ,rz...,,u'C h ,,,a nlYe,... ... ..,iivffiLvi Not AApplicable 0
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.
ASSigned Affidavit Attached Yes 0 No 0
.•:^iilit '�1ai�i� 'g'i� ��u t t ti
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) 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
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GitR of Northampton i-
$isax<y4 rat are • ncr2ic
Virim •
tr.�a DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street e Municipal Building
NorEhamgton, Mass_ 01060
�./.WORKERS COMPENSATION INSURANCE AFFIDAVIT
(licensxltsamittac)
with a principal place of business/residence at:
1779ilt t��1( F;n1Qr4d . m na��. (phonerT,e)
strcUalythaICPp)
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) (£i>prtion Dote)
itat () 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) (lnetrance Company/Police Number) (Expimtimi Date)
(Name of Con2acor) {insurasecc Compary(Poflcy Number) (Expiration Dale)
(Name of Contractor) (lasurance Company/Policy Ntmdxz} (Exwiradon Date)
(Name of Contractor) (lasurance CompanyiPolcy Number) (Expiration Date)
(math adkeoml*tC itnma.ry to ohm tdoruuuou p t.amng to dl demon)
(?j" I am a sole proprietor and have no one worbng for me.
) I am a home owner performing all the work myself
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ml more then Sort tants m which tS,b-w..'cczvidm cv thn gtw;yb am:Annam there,:cc oat gtionnollyoonsidercd tobe
e,mploycv unity the wokas cciw wstim Aa(04,1522= (5)),applkvian by a boneowwr fors beau a pamd tiny evihm arc
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:than:ofan anploytc wader the Wotkdt emgm utioe rant
^ undaaund th*a copy of Win tt. wt t„+ may be towao{.d to the ' n rof idumid nridva&Otlim of inwwm for Om
xvcagevcrifitatim andth*tfailum to scare owra ,tad&sccuon 2M ofMcL 152 can ksdto tad i,ros ccofmmiaat pca+ititt
mouton oft Eft ofap to S1}00.00arWs utgavtauyat of up to Ott ran and civil pantile.in tr f t Oft stop Work Ott mda
fore 01 5100.00 a day agunst m[.
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Signahm ofL(ocalsce/Pcmiunc