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30C-008 (7) BP-2005-0900 GIs#: COMMONWEALTH OF MASSACHUSETTS Aw"o- CITY OF NORTHAMPTON Lot: -001 Permit- Building Category: BUILDING PERMIT Permit# BP-2005-0900 Project# JS-2005-1250 Est.Cost: $2500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Robert Thibodo 118441 Lot Size(sq. ft.): 53143.20 Owner: KIELY MAUREEN Zonin&SR Applicant: Robert Thibodo AT. 435 FLORENCE RD Applicant Address: Phone: Insurance: P O Box 201 (411) 556-n-391. NORTHAMPTONMA01061 ISSUED ON:3/28/05 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 Occupangy OccupancySi nature: FeeType• Date Paid: Amount: Building 3/28/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo c, ! ,3r Dapartment use only City a_f.N, orthampton Status of Permit: 1C&ilding [department Curb`Cut/Driveway 1 P� Z� 212 Mai Street Sewer/Septic hvailab lity_ __ _ „ :Boom 00 Water/Well Availability, 6 , MA 01060 Two Sets of Structural V�Fibne X13-587.1240 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 This section to be completed by office 1.1 Property Address: ',L; �l����� R� Map Lot Unit__ - M4/1 � _/ i O/O&O Zone —Overlay District _. T11 /V Elm St. District _ _ ._ _ CB District_ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address- Telephone ��JJ Signature 2.2 Authorized Agent: i dao _ Po /3dx gal or V via_6l Name(print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS F__ I 'Item-- 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) a 600" Check Number 223 1 S07 This Section For Official 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 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 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 No IF YES, describe size, type and location: SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ TRoofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: Re-no , e,)66r)a1 P.!' roo io (4id_ QC2 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll 0 • Sheet 0 6a:If New hdd-tb-and or"`addition'to'exi!"ting housing, complete the'f611owinj!: 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 �I��(,r�el� ���'(� as Owner of the subject prop i hereby authorize O Q TT+ \ PJ to a i my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner V Date as Owner/Author' Pz_ Ao n hereby declare that the statements and information on the foregoing application are true and accurate, to the b of f my knowledge and belief. Signed under the pains and penalties of perjury. --BOB 1 t1BODD Print Name ' �} 5•- o S Signat-ureof'Owner/Agent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number oX 20 l i�©�Tt1 R t�l P To N, 11 R o lD W 0 6 5lo q q Address Expiration Date 1413 - 59 7- 17 4 43 Signature Telephone JL'`�Rekistered HomeImprovement Contractor Not Applicable ❑ Company Name Registration Number �jo� Tl��6oDo, `� do�t �� S � DtNC� 119441 Address u Expiration Date PO C3M-2-oi �of ar►�p1ar�, MA O O6phone S.217-17" 3 �- 22- 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 affidz will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ 11. Houle 0NN,ner rxemntion The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fami ie and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner a& 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 b 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 perso 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 i i 4CIiAMPJ0 9 _1 �1 of NUr#Ijaillpt1T1t � 6 �aisac}Insctta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT with a principal place of business/residence at: (phone#) (street/city/=irizip) 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 wor dug on this.job: (Insurance Company) (Policy Number) (Expiration 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/PoGcy Numbcr) (Expiration Date) (Name of Contractor) (Insurance Company/Podcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (ExTiration Date) (attach additioail shc�ifne�awy to include informstioa pertaining to all oo�racton) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be awart that wElo bomcowners who employ persom to do marts.,,,= consbuetioc or rtpair".Uric on a dwelling of not mode than dune units in which the homoov n r ezidcs or on the vvjz it appurtenant tlratto sic not grncrally ooandered to be employm under the workers oomp=s4ca Act(GL152,=1(5))•application by a homeowner for a 6ccase or permit may evidence tho legal Bahia of an employer under the Workeet Compomatioa AOL I underrtand that a copy of this cuLcm cd may be forwarded to tbo DepartmmQ of Industrial Ac6d=&O1Soc of[asurwm for tha ooveragc wnficatiou and that failme to acture eovemp larder section 25A of MOL 152 can lead to tba imposition of-ilial peaaltiea oomittiag of a fine of up to 11,500-00 and/or imprisonmeai of up to one year and dQ p=aths in the form of a Stop Work Ord--and a fuse of S 100.00 a day against mo_ For deputmmtal use only permit Number map-4 Lot#