23D-091 (4) f
171 FEDERAL ST BP-2000-091 1
GIS#: COMMONWEALTH OF MASSACHUSETTS
lap:Block:23D-091 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-091 1
Project# JS-2000-1680
Est.Cost:$50.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Punska 039852
Lot Size(sq.ft.): 23609.52 Owner: BYROM HENRY G&RITA A
Zoning:URB Applicant: John Punska
AT: 171 FEDERAL ST
Applicant Address: Phone: Insurance:
5 Dimock St (413) 584-5533
LEEDSMA01053 ISSUED ON:4/25/00 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR WATER DAMAGED SIDING & FLOOR
JOISTS
MOST THIS CARD SO IT IS VISIBLE FROM THE STREET
nspector of Plumbing Inspector of Wiring 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 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 4/25/00 0:00:00 2396 $50.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2000-0911
APPLICANT/CONTACT PERSON John Punska
ADDRESS/PHONE 5 Dimock St (413)584-5533
PROPERTY LOCATION 171 FEDERAL ST
MAP 23D PARCEL 091 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c7Q3 jl0 A5d
Typeof Construction: REPAIR WATER DAMAGED SIDING&FLOOR JOISTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 039852
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
_Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co sion Permit from CB Architecture omrm. ee
Signature of Buildin fficial 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.
*, .
NIP I\
--
r .._ C; � 11 `� �% Department use only
I �� l! , Ci# '•f Northampton Status of Permit:
�� 20� B" lei g Department Curb Cut/Driveway Permit'_._.
APR 19 Main Street Sewer/Septic Availability
lJts n�F'p , rGjlpp S
-•om 100 Water/Well Availability
LJhon
ort ari•ton, MA 01060 Two Sets of Structural Planse 413-587-1240 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:1.
7/ .- S- Map Lot Unit
nU n`v�`� /
0, 4 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: `_..—
/1 Pen is R5 Kim ,,-2/ fh®Q S AArvi,4/1,/ 4 ,2ii, ,
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A ent:
`in NI b1`rnnck ST L pc1S ,1
Name 7' h
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 A` ."`772 Qp (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 p?3 '''(e, 0��
This Section For Official Use Only
Building Permit Number: 91( 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 j/ 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:
CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing ❑
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding(G 3 Other [ ]
Brief Description of Proposed Work: &Ad— 42076r-de,rn aS a ",i,l,;) q liJ f /c,c,- )v)S7S -771 'd2e.c_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
64611 New.hou :and or addition to existing housing, complete the fol.lowifi
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?
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, I �f� k�lc�m <` l , as Owner of the subject property
hereby aut rizen �1✓1 ��SQ to act on
my behalf, in all matters relative to work authorized by�his building permit application.
Signature of Owner Date
I,
JU h �� "`ti� , as Owner uthorized Age
hereby declare that the statements and information on the foregoing application are true and accurate, to y
knowledge and belief.
"`gned under the pains and enaltieslI of perjury.
Jo I K o fit dl S ,/f
Print N e/,‘ (?0,,./k
L///
7//10
Signat a of Owner/Agent Date
1
crCTION 8-'CONSTRUCTION SERVICES
l Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: 111A 'S A ( c>-2
License Number
L S
Address Expiration Date
/i 24, - 7,1(=- S3 s
Signa re Telephone
E; , ' Not Applicable 0
7/0 k A k,,r.s Al} /(')o �`-)
Company Name Registration Number
Address _ Expiration Date
Telephone 1`� �S )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.
-";ned Affidavit Attached Yes fd No ❑
I. '' "1 ptton''
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
• . .
_- tn>r pi.
ooaogti � Al`E
(rtN of O1fLupfoi
= 'ftsaarhn6rfl'd' �R•- E� m—•
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�— DEPARTMENT OP BUILDING INSPECTIONS
v_ ���;
212 Main Street ' Municipal Building
Northampton, Mass. OlOGO `s
WORKER'S COMPENSATION INSURANCE AF1, 1)AVVT'
-- c—roj loft avx..51.--
(liccusedper'mittcc)
with a principal place of business/residence at:
--:'V"`Gc - 'S CSz2c6S (phone) SBiE -
(strt/ci ty/staierzi p)
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 rig on this job'.
(Insuranc Company) (Policy Number) (Expiruon Dale)
( ) 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/obey Number) (l-..,>.r)uon Data)
(Name of Contractor) (insurance Company/Police Nwncrr) (EXDu tion Date)
(Name of Coni acior) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaath additional Meet if amasser}'to rnc..uek infaruaoo pertaining to all n,or,-e.-,aria)
( am a sole proprietor and have no one woridng for me.
( ) I am a home owner performing all the work myself.
NOTE:plcsc be awns that wbcdo homeowner who employ pa-sons to do me -.n-- ooaz5vct.ioo er repair work on a dwelling of
not more than three units in which the bomoowocr rtaidct or on the grounds appurtenant tbccto art not generally considered to be
employers under the work&c o1im Act(GL152n 1(5)),application by a homeowner fore lima%or permit may evidence the
legal status of an employer uoder the Worker's Compemation Act_
I understand that a copy of thin rederoced may be forwarded to the Dopareneat of lndarcri.l Ao 4O D'.01Boo of Irnzuaoce for the
eoveragc vctiIcatioa and that failure to aa-tirc covczagc under section 25A of MOL 152 can Irxd to tba imposition of criminal pcaallios
ooc:L ing of a fine of up to S 1.300.00 and/or imprisoamcua of up to one year and cavil pcialtio in the form of a Stop Work Order and a
fine of 5100.00 a day against me
�/ roe depK• m*r•t use only
___ /Zg
// PllN/ Map: _ Lot " —
Signabirt f LiocnsceJPcrmiUcc L}3te _