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23D-113 (3) 200 FEDERAL ST B P-2003-0691 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Bio a:23D- 113 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0691 Project# JS-2003-1116 Est.Cost: $8500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Kent Hicks 066104 Lot Size(sq. ft.): 85377.60 Owner: COMEAU JEANNE Zoning: URB Applicant: Kent Hicks AT: 200 FEDERAL ST Applicant Address: Phone: Insurance: P O Box 119 (413) 238-0122 WORTHINGTONMA01098-0119 ISSUED ON:2/20/03 0:00:00 TO PERFORM THE FOLLOWING WORK:RAISE ROOF PITCH 2ND FLR BEDROOM FOR SHED DORMER 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 2/20/03 0:00:00 5629 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo File#BP-2003-0691 APPLICANT/CONTACT PERSON Kent Hicks ADDRESS/PHONE P 0 Box 119 (413)238-0122 PROPERTY LOCATION 200 FEDERAL ST MAP 23D PARCEL 113 001 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 . r9-' SSID Typeof Construction: RAISE ROOF PITCH 2ND FLR BEDROOM FOR SHED DORMER New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066104 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: • pproved Additional permits required(see below) 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 Street Co 'ssion 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. 1 � ce,1 City of Northampton S tusoff Per' tt 47. Building Department Curb C�t Dive y •er .pv �: 212 Main Street Se erl e t �ga►i bl t Room 100 Wa er/Well Av�atlab l ty . Northampton, MA 01060 T cSets of�Str cturai P anC��� -yy�• +xa w , phone 413-587-1240 Fax 413-587-1272 PIMSite,Plansq� r �F� =fi OtperSpdetfy d` ' ,_ 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:oo A Fecie .'c�, / Sl;'ce/ Map c79L3 J Lot //3 Unit Zone /aft Overlay District rIa'rc /IJ4 ✓lam Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: IA d Name(Print), 1 Current Mailing Address: y/3-- g6 .- 3 31/9 A.? r. ,r� . _ Telephone Signat e 2.2 � Authorized/ Agent: ut y� 4/ ' 1\ C°il / /i s / , o, 80x / /7 ./„•,/<i,'..� an� dC�/t,cl� Name(Print) Current Mailing Address: /Z - y. 3 o/2- Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee C ice) c 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 ��pp?? This Section For Official Use Only Building Permit Number: i 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 /©2 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 1 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) El Roofing ❑ Or Doors 0 Accessory Bldg. ❑ DemolitionD New Signs [ I /'Decks [ ] Siding [�] Other [ ] Brief Description of Proposed Work: k S e ,44> L ` ii iA 2II �"/oo/ ^coM -�o, <�c.'l d'.r.•^�i. Alteration of existing bedroom v Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement _ Yes ✓No Plans Attached Roll 0 . Sheet V 6a:IUNew houserand`or...addttion= o7ezi§ting 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 fLf�' I,S !/'G•` .;f ,,',"` , as Owner of the subject property / to act on hereby authorize ie .,/ `cKs- — my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 4,/ / / r S , 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. Signnee ` under the ins nd penalties of perjury. Print Na/ffm��e ' 2 / `zl �Da e0`n Signature of Owner/Agent SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 4N6ot Applicable 0 Name of License Holder: n * Q 6 b JOY l/!1 1 //,/ / ��//! cr License Number eue//9 ,4_, Addre4s i Expiration Date /01 4 /3-,2 r-op„a._ Signature Telephone i a liAMmpreci ement Contractor a � ' Not Applicable 0 �/ // �,� ��; � ate,��� �,.�.��. <� ���€4.�€ ��. Company Name Registration Number Address J Expt6tion Date Telephone 'J3 .Z3e-D/Z — 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 0 No ❑ tO o, U 'le 2I a,:a s i litti,11 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 0 oy — aIti.AM pi. � Eta (ri x f Nnlr#Iianipthn _* v ��� • 4�, asanchnactta Miliki= LYk4 MI__ DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, Mass. 01060 , r'� WORKER'S COMPENSATION INSURANCE AliIt'IDAVIT I-, 4,,, i /.,/_, Oi censee/perm_i ttec) with a principal place of business/residence at: • f ' le 41oT�-, il,,,i / A 0/G'� (phone#) 'y/.-,l3E'-6/ t' (krnet/city/state/ap) 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 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet ifnee e,sry to include information pertai.ning to all contractors) ( 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 homeownm who employ pa-sons to do cesiatcaaace,construction or repair work on a dwelling of not more than throe units in which the homeowner resides or on the grounds appurtenant thereto arc oot Generally considered to be employers under the worker t ccrrpeasation Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Workoes Compensation Ad... • I understand that a copy of this rtxt..,,..,s may be forwnrdod to the Department of Industrial Aoci,' >'Offioe of Iasurance for the Coverage vcri£caiioo and that failure to sure coverage under v-tion 25A of MOL 152 can lead to the imposition of criminal penalties oomistntg oh a fine of up to S 1,500.00 and/or it prisoomusi of up to one year and civil penalties in the form of a Stop Work Order and a find of S 100.00 a day against tnc. • For dcputnxntal use only t • Xi Permit Number Signature of Ltccnsee/Pcrmittce Cate (\ s A p Q fl — .. r II . - I F E B 1 2 2003 ' x cs LP CA 0 \ ZY• O DJ # \ 1 ‘ D...... a -,, P i , r o � o Z 1- o 0 s 1Y 0 ye . / X tt." 00 O T x O n > % .) 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