30C-007 (2) . 4
423'FLORENCE RD BP-2001-1061
GIs#: COMMONWEALTH OF MASSACHUSETTS
}:Block:30C-007 CITY OF NORTHAMPTON
is
Lot:-001
Permit: Building
Category:roofing It BUILDING PERMIT
Permit# BPW-OOJ-1061
Project# JS-2001-1880
Est. Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sg.ft.): 40815.72 Owner: MORONEY GEORGINA L
Zoning: SR Applicant: James Roberts
AT. 423 FLORENCE RD
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:6/18/01 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 Wiri" D.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 OIANORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/18/010:00:00 1305 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability_
Room 100 Water/Well Availability--
Northampton,
vailability —Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413.587-1272 Plot/Site Plans-----.----
Other
lans.___- .-___Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit_
7 ✓ Zone_ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
A)
Name(Prin Current Mailing Address:
Telephone
Signat e
2.2 horized Agent:
NarnowX
Trint) Current Mailing Address:
atur Telephone
CTION 3 - ESTI ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building X x (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 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
i
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 L---- 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:
s
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding [ ] Other [ ]
r
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet
sa. 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?
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 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-2"o.C - /4 DiE'�j A) as Owner of the subject property
hereby authorize ge Z�OPC/A)C,3 to act on
my behalf, in all matters relative to work authorized by this building permit application.
A 6 i
Signature of w r Date
as Owner/Authorized Agent
herebydeclare that the sta$��ents a informs ion on ttl ee�oregoing applica iota are true and acc ate, to the best of my
knowldge and belief. �_- �/G
7 tk__�
Signed under the pains and �nalties o perjury.
Print Name p
i
�atuWreof Owner/A nt Date_ `
I
SECTION,$ C015TRUGIION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ '/`
Name of License Holder: //�/ `, `t
I Licens Num e
Address Expiration Date
,�-' —
T, � �j
Signature Telephone �S —,/-7 ( Q
s
rte` rNot Applicable ❑
9.-
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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11.aw,00,1me oWnerTix &i5fiori
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 Massaohusetts 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 a o lal Zo ing Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
�O C �Toti ��
A `E vlt-L) of �\T0a:tjjUlll:ptoll
.61 a5aitch ngrlIs.
'
c� DEPARTMENT OP DUILDFNG INSPECTIONS
212 Main Street ' Municipal Dudding
TNorthampl.on, Mugs. 01060
\VORICER'S CON'CPENSATTON INSURANCE AFAVIT
I � .
(li ccvsccJpcmmi t Itx)
v.9th a plincip place of business/residebce al:
(SU=Uci ty/stale/zip)
do hereby certify, under the panes aod penalties of perjury, i.hat
O I am an employer providing the followine worker's comocnsadon cove 2ge for In),
eluployces wotIang on Oils job.
(lnsuram= Comm-my) (PoUc-.NtL-ter)
( ) I am a sole proprietor, general contractor or homeowner (ciuc;e one) and have hired
the contractors listed below wbo have the follo\vi.ng worker's coopenQdon policies:
(ilatve o.Coal actor)
(Irisilrancz Colnpanyili ok-, NLirnt---:)
(N-,,uc of Contractor) 011S'W--DCC Company/Po!ie}, Nw-nccr) (Expir,:uon Dzle)
(Name of Contractor) Ga%rauce Compan)'/PoUq- Numtu) (Expirooa Date)
(Name of Contractor) (Insucanct- Comp-,r /Pob y Number) (L-xpi-ation Daic).
(etl�ch dpi ioesl r.'ucf if ooeea,ry to include iafort on pertaining to.L oosr-moo�)
O I am a sole proprietor and bave no one working for me.
( ) I am.a home owner performing all the workJmyself.
NOTE:pl=c be ewxre tb 4'.•O boar_a teen N'bO amploy pasom t0 da=Am -••*o- wuq c repair-ork on d..c1L:g of
ant Core tti.a tbroe L"Ihi in%%46cb the bomoowocr rciido or m the grouo43 appurt.- r+tbceo«ooe gCraaav w<=:d7cd to be
curploy—un'c tbc..akc a 0=09c=1loe Aa(GLI 52,=1(S)�&MUc36on by•bomooava fcr:tia=x or permit ra:y nidcooc tl:c
IegJ naau of so exployec uod—deo W*,i .Compomatioo Ad
1 uodest.od dW a oopy of thu mtemms=ay be I.,—,id to tho pep.rzmooa of lod.wid Aeodr.3i!OIL—of trcw000 foe the
-v-&"-hailcaioo s fd ttu Liltac to eocurc bovcrIge under soctiop 25A of MOL 1 S2 no Ind to the i¢poaitioa o(aimiaal pcaJtie
. oomixing of►fmc of tip to S 1-500.00 and/or impr60awccd orup to ooc year cod a%il pmal'ua io 6c forth of a Stop Work Order Lod.
firm of SI00.00 a asy tpinst Mc.
F«dcq.rtn.y,t u.e Only
permit Numbcr _
Lot
Si to f Li �crnuttcc —D