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23D-133 (2) 59 HINCKLEY ST BP-2001-0075 GIS#: COMMONWEALTH OF MASSACHUSETTS lap:Block:23D- 133 CITY OF NORTHAMPTON -ot: -001 Permit: Building Category:roofmg BUILDING PERMIT Permit# BP-2001-0075 Project# JS-2001-0122 Est.Cost: $5650.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: C & T Construction 116981 Lot Size(sq. ft.): 10628.64 Owner: CASSADO HENDERSON&BEEBE&LE Zoning:URB Applicant: C & T Construction AT: 59 HINCKLEY ST Applicant Address: Phone: Insurance: 15 Fairway Drive (413) 586-4965 FLORENCEMA01062 ISSUED ON:7/20/00 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP, INSTALL PLY & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Tnderground: 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 7/20/00 0:00:00 2672 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo Department y 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, MA 0106e Two Sets of Structural Plans phone 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 fin/,r( /p- Map Lot Unit Tf p ^ / Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 1 2.1 Owner of Record: 1,. ,/4,449--" 4-51 O e rn / . ime(Print) Current ailing Address: LkaTe� lephone ( .� Telephoned Signature 2.2 Authorized Agent: Nam- '' 7 Current Mailing Address: Si: Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building S L (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 Pudding 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 V 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 ❑ Replacement Windows Alteration(s) 0 Roofing Or Doors 0 Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work:s 7?-H�A�' i �� " �- eft � ��/� Alteration of existing bedroom Yes �/ No Adding new bedroom Yes No Attached Narrative P Renovating unfinished basement Yes , No Plans Attached Roll . Sheet 6a. 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? 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.-CLI1Z4i stdCa' , as Owner of the subject property hereby authorize / ��6. ctfo/7 to act on my behalf, in all matters'relative to work authorized by this building permit application. u —7 28' 2-&t,� 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. caned under the pains and penalties of perjury. Print m /, Signa e o Owner/Agent Date SECTION 8 -CONSTRUCTION SERVICES Licensed Construction Su ervisor: Not Applicable CIN Name of License Holder : r, /v /� Cs 06-)'r� !f �� License Number fii1,,,,..„7 ,, /✓/ /,- 3 / 0/2,-- Address r Expiration Date Signature Telephone 9. Registered Ho e Improvement Contractor: Not Applicable ❑ Company Name Registration Number tvc 41.)--, Wor-r -fi' (2/t7 4 ii , Address / Expiration Date Telephoner '— 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 d No 0 11. — Home Owner Exemption 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 • • - , I' OV%Alf pl• a� Eit Curt IT of rf1ia pfon ► =*=IAlI r 9��Jo:4'_ P 6 iassacinsals =li ` ��=mayi. DEPARTMENT OF BUILDING INSPECTIONS• c.,4_ -z`i f 212 Main Street ' Municipal Building Northampton, Mass. 01060 ow"• WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, K 5 i ) with a principal place of business/resi ence at /S 1%/ 7 P1':/4/ cat (phone#) � 074�, • 7 (sti xticity slateJap) do hereby certify, uder 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 Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necessary to include information pertaining to all contractors) (Iaam 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 homoownets who employ persons to do ma itemso"-,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 not generally oomidatd to be employtas under the worker's crrrtp<ircatioa Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal clatxua of an employ under the Wociccea Compensation Act_ I understand that a oopy of this atatemcat may be forwarded to the Depactaumt of Industrial Mxideat'Oloo of Imrua000 for the coverage verification and that failure to secure coverage under section 2SA of MGL 152 can lead to the imposition of criminal penalties oomisting of a fine of up to S1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a fine of S100.00 a day4gainst me. !,i �� For dial tree only G �+/' Number 7//' '•Map Permit Lot# of Li ermitiee l