25-080 (3) tNM1 uWWkNDY BP-20030116
GIs#: COMMONWEALTH OF MASSACHUSETTS
MA~25.0801 CITY OF NORTHAMPTON
Lot: -001
Permit Building
Cateuorv: BUILDING PERMIT
Perrim BP-2003-0116
Prv'ect# JS-2003-0229
Est.Cost $12000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa.ft)� Owner. FOURNIER MELANIE A&DAVID W FOURNIER
Zoning7 SC Applicant: FOURNIER MELANIE A & DAVID W FOURNIER
AT.- 129B RIVERBANK RD
Applicant Address: Phone: Insurance:
129B RIVERBANK RD
NORTHAMPTONMA01060 ISSUED ON:811/02 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS, DOORS &
VINYL SIDING
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: Flre Department Flreplace/Chimney:
Rough: OIL Insulation:
Final: mo 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 8/1/020:00:00 3724 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
i of Northampton
JUL 30 2002 Ing Department
2 2 Main Street
DEPT OF BUILDING INSPECTIONS Room 100
NDg1FNMPIDN,MA 0106)) pton, MA 01060
phone 413 587 1240 Fax 413 587 1272
O o
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Adm: This sectio" o toalaT
E s
��i l5 Q �erbanl' /ld M — Mx N:
Zone Overly ist0' kY +
Elm St Distnct CB Di3trwt
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N11.d�=1— Current Malting ss
Addre '
/�// KLb MSgK• dress
Telephone
Signature
2.2 Authorized Agent'
Sg.,e n) abu'e
Name(Print) Currant Mailing Address:
Signature Telephone _
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
cr,raniple,ted b ermit aendlicant
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) f;.0M'6D Check Number
This Section For Official Use Out
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 -7437 s , (-t-
Frontage
rFronta e
Setbacks Front '{0
Side So L:_R: L R:
Rear q0
Building Height �S /
Bldg. Square Footage
Open Space Footage
(Lot mea minus Wig&paved
16017
,.km,)
q of Parkin Spaces
Fill:
volume&Location 0
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW—X— YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW _p_ YES
IF YES: enter Book Page_ and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO -X-- 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_
Nox
IF YES, describe size, type and location:
Sg lok 3 U I4` �1f g11OF PROPOSED WORK-( he all apolicalole)
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing ❑
Or Doors ]K
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] SidingX Other [ ]
Brief Description of Proposed Work: nfl-j Lo-m aws f EXT,dmll (gyno.i S1`drnq
Alteration of existing bedroom _Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes -X—No
Plans Attached Roll❑ Sheet❑
Bp�iftNeWa o dfi'f�2tlditiolt"to�ezistine�Rou3in�'"coFi�pl@te""fttfe f611bY(+ine
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?
In Type of construction
L Is construction within 100 it. 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
I, _ &'d `[/ I'u41'q!t( as Owner of the subject property
hereby authorize F�4+1fU r-0of a,t(/ _ toactor
my beh, + in all rpatters
relative to work authorized by this building permit applicatipon.
Signature of Owner Date
rd ��uTwr �.r , 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.
Signne�d under the pains and penalties of perjury.
`drO.t..f i L f
Print Ndjrfy�
Signature of .mer/Agent Date
f
SECTION 8-CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :—
License
older : License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION SO-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§25C(6))
Workers Compensation Insurance affidavit must he 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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 buildine permit.
As acting Construction Supervisor your presence on thejob site will be required from time to time,during and upon
completion ofthe 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 maybe liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliwcc with the State Building Code, City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated,
Homeowner Signature , _. ._
ySrWIYT �-\
Gio of ' crtam{tfan
g A Nh -
9 ( Auuahmall"
e
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
(licenseelpemvttee)
with a principal place of business/residence at,
(pho❑e#)
(strzeUcity/statrlap)
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:
(Insurance Company) (policy Number) (Expiration Daze)
O 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 Con=aor) (lnsunncc Company/Policy Number) (Expimaon Date)
(Name of Coutmaar) (Lnsurauc c Company/poiicy Number) (Expimoon Date)
(Name of Confraaor) (Inv rance-Compy/Pulicy Number) (Fxpimnou Date)
(Name of Contractor) (Insurance Company/policy Number) (Expiration Due)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
roTE:rlw.�l,�¢a-+R uw.wa¢conrow,.,�w�vlm w-wsem ..,, �G;oo«Rwir..a�k oo.e..<u;�s or
dorm awu as ted.as�.uoo nn(cLtszPtCs)z=w6m�sr.nw�w�r�¢c�.,�«r�r^uy�;•+ma�x
legal nim.of.a�ior.c�a..w¢wo�ra com�•nan na.
I ondo-wnd ihrt a wGY ofUw mtemmt m.Y be fmwwd.d to Ne Dryvmn.t oral fiamid Amdaei OILoa NI®u.om rot Wa
eoucvge vviLenim and Nat fnilwewz«vrt w�eceb wda Yciw 2SAof MOL 131 oolmdb��6w of°'��a°°�Sn ,
ma+iYwg of¢rwe afapm Sl3W.W uvV«�pvo®-.mofup bore yvr endavd pmrl4a iv the(oemof.Slap Wak ONa mda
fim or2lOO.oe a my a&tival me
F«sy woowy
Permit Number __
Mad) Lot M _
Stgwzaan of Liccnscelpermittm �E k
F