23C-080 (2) 42 BLISS ST BP-2003-0337
GIs #: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 23C-080 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0337
Project# JS-2003-0565
Est. Cost: $3750.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 17685.36 Owner: JOHNSON DIANE&JEANETTE
toning• URA Applicant: JOHNSON DIANE & JEANETTE
AT. 42 BLISS ST
Applicant Address: Phone: Insurance:
42 BLISS ST (413) 586-6569 (�
FLORENCEMA01062 ISSUED ON.1011102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT GARAGE INTO BEDROOM
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 Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/1/02 0:00:00 937 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2003-0337
APPLICANT/CONTACT PERSON JOHNSON DIANE&JEANETTE
ADDRESS/PHONE 42 BLISS ST (413) 586-6569 Q
PROPERTY LOCATION 42 BLISS ST
MAP 23C PARCEL 080 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction:_CONVERT GARAGE INTO BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94MATION PRESENTED:
Approved Additional permits required(see below) sj�v6
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Stree ommission
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
r
D apartment use only,.
Mi L I Northampton Status of pemlit:
L�)l� I rig DepartmentCurb Cut Driveway Permit"
1
121 Main Street Sewer/Septic Availabilityv �
SEP 2 5 2002 1 oom 100 Water,'V,'eli Availabi ity _ T
No hanipton, MA 01060 Two Sets of Structural Plans,11
.
DEPT OF BUllRrl','1NrPECi 87. 240 Fax 413-587-1272 Plot/Site Plans
NORTHAVf17( MA OlnrO 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_ C,-22 Lot Y(9 Unit
Zone Overlay District
(21
®�Q Elm St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: `
.� Xf
�h-S�f7 �� t�/WSJ ` -7_/ i �r�C e
Namme(Print) Current Mailing Address.
v; ,Cyt ��+ , Telephone
Signa ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � o 6' ---- (a) Building Permit Fee
2. Electrical J (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 D
This Section For Official Use Only
Building Permit Number: ' ��T— Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r �
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 63
Setbacks Front
Side L:,/,()_R:_/ L: R:
Rear Z
Building Height
Z . 00
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?
NOy 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
1 IF YES, describe size, type and location:
ry
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s)X Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: CAizei 4 1 Ag c o"l–e'9 fe-- J•/7 4& '4APa1/—(3 l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6 �ffNe�hos� anloraddition 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
1 , 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
-3 2 (e � O �
Signature o wner/ gent U Date
ti
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
et7t Not Applicable ❑
Company Name / Registration Number
I, N,n 'e, wa 1✓ ��c /1Q.���/
Address / Expiration Date
f - c , G e :;L Telephone s em .,v5Y Z06-3
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...... ❑
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 4LCI •- 1�✓�`- i
4-�tiAMP�O �\
B=o � °fl Crz�r ,orf ��#f�ttl�i�#iii -
�a5EAC1I ttECIIE
cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMTENSATION INSURANCE AFFIDAVIT
(li censerJpermi flee}
with a principal place of business/residence at:
(phone#)
(st =Ucity/stalrlap)
do hereby certify, under the pains and penalties of pegury, that.
( ) I am an employer providing the following worker's compensation coverage for my
employees working 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 Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional s+cct if noccssary to inc}ude inf«miiioa percaiuing to rill oodsaa4n)
(ol'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 aware that while hcmcowsxrs who employ paziom to do nmi„r,- ,ace bion er repair work on a dwelling of
not moee than three units in wfi ch the ho=owncr raids or oa the grounds appurtcna i tba do arc Dot Generally oomidcrrd to be
employers undo the woticcr s caaTCas4oa Asx(GL152,ss 1(5)),application by a homeow acr for a lana a permit may Cvidcnoe the
legal ctatua of an employs under the Worked Compensation ACL
I undrntand that a copy of thin rtatemcnl may be forwarded to tbo Dcpertascuf of lodutrial Aocidca&Of Goo of lawraDco for the
covazge verification and that failure to scenic coverage under section 25A of MGL 152 can lead to the imposition of-MW P-ddcs
consisting of a fine of up to S1,500.00=Nor imprisonment of up to oDe year and civil pmalties in the form of a stop Work Ordcr and a
find of S100.00 a day against me
For al—only
Permit Number
C L lvfap# Lot#
t Si of Liccnseelpermittee e
0.406 TOTAL LAND VALUE; 42,300 SALES INFORMATION
DATE TYPE PRICE VALIDITY
19971001 LAND + BLD 85,002 M
9704 LAND + BLD 124,624 L
ADDITION DATA
Lower Level First Floor Second Floor Third Floor Area
A Opn Frm Prch
B is Frame 42
C is Frame 60
D is Frame 224
EF196
rame Garage 308
F Frm Utlt Bid 64
H
�0
AL DWELLING INFORMATION T E,{�
'AL FIXTURES:
IM: X
IM: X 8 Fru
T4s m P't 3y �t'RA)I C
NG DATA
28 14
ODELED: $ 1Fr
REMOD(Y/N) /Q
ODEL (Y/N)
20 14 �� 1
22
�. 1Fr l
15 14
),TA �-
1
PURPOSE PRICE
4 28 A/2Fr/B
t�5
OFP
6 s
0.406 TOTAL LAND VALUE: 42,300 SALES INFORMATION
DATE TYPE PRICE VALIDITY
19971001 LAND + BLD 85,002 M
9704 LAND + BLD 124,624 L
ADDITION DATA
Lower Level First Floor Second Floor Third Floor Area
A Opn Frm Prch 42
Cis Frame 60
is Frame 224
D is Frame 196
E Frame Garage 308
G Frm Utlt Bld 64
H
rt
•fit:
.i
i
fAL DWELLING INFORMATION
.Y•
IAL FIXTURES: 8
IM: X
IM: X 8 FrU
NG DATA
28 14
ODELED: 8 1Fr
REMOD(Y/N)
ODEL (YIN)
tFr/
1422 FrG
/1Fr15 V14 1FrATA
PURPOSE PRICE4 28 ;i