23D-128 (9) 04
BP-2004-1333
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1333
Project# JS-2004-2002
Est. Cost: $24990.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PATRIOT HOME IMPROVEMENT 115804
Lot Size(sq. ft.): 11586.96 Owner: PONTBRIANT ARTHUR W JR&ELIZA
Zoning:URB Applicant: PATRIOT HOME IMPROVEMENT
AT: 16 WINSLOW AVE
Applicant Address: Phone: Insurance:
820 UNION ST (413) 731-8082 WC
WEST SPRINGFIELDMA01089 ISSUED ON:6/28/04 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SIDING & REPLACEMENT WINDOWS
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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/28/04 0:00:00 7397 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
•s ,,
'4t y : fie M b
City of Northampton .. 4 4' §�`
Building Department . Fee
212 Main Street y`
Room 100 -• . . ..
Northampton, MA 01060 41001
phone 413-587-1240 Fax 413-587-1272 lelitAii#0140 # Mr•.*.
1.. 03g4!c�`
APPLICATION TO CONSTRUCT,ALTER,RED `,- h •. 1- A ONE OR TWO FAMILY DWELLING
j JUN282004 1L )
SECTION 1-SITE INFORMATION
Uk";c"El .+Uj"iG vggic4�_is
1.1 property Address: Nn¢T4�,k TON,MA 010i hiS on to be completed by office
lj i'n SI,OW A Map Lot Unit
A1(9 fi-YYl A YYs Da t Zone Overlay District
t
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:
#U. . E 7.A' Ei 1.4. ?OAfT tAAVT
Name(Pint) Current Mailing Address:
a rJ� I JLU. L1 Telephone
T
Signature
2.2 Authorized Aaentl
'PAT RtDT Roife T AI PPDV EM E,UT _ 810 ur t ,u S r 141.s P DA/6-F tELA NA . Ol o$w
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 g1-1 l L !i`60 (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 '"75
lt //
This Section For Official Use On
Building Permit Number:_ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I •d
e2 T :60 f+0 82 unr
n
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 % 1
(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
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:
2 d
e2I :60 1,0 82 uni'
SECTION 5- DESCRIPITON Or PROPQ_SED WORkicheck ail aoplicable)
New House 0 Addition 0 Replacement Alteration(s) 0 Roofing ❑
Windows Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs( Decks [ ] Siding [ ] Other[ ]
Brief Description of Proposed t
Work:_ _. /l/E 1')i /(�' y 1, kV/fl De Lit/5
Alteration of existing bedroom_ Yes No Adding new bedroom Yes No
Attached Narrative L Renovating unfinished basement Yes No
Plans Attached Roll iij-Sheet
6 :I llievir:house:ta;r>iti:oradditionli cis f[tg::h itisti eciM letelhe follovvt t
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 _,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
I _, 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.
Ai,-0 ►i Q c,14-L (k K
Print Name
•
E •d
e2I :60 170 82 une
a- ,
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8 l itpsed ConpttpctQp Supervisor: Not Applicable 0
Name ofjicense Holder:
License Number
Address Expiration Date
Signature Telephone
�' + .Iin�p „. ', ... :. Not Applicable ❑
Joc I ) Du t IdQ� / b-ft /4oc 10yr!i it e_vit calf i10�(Co luny Name Registration Number
IlL / av0(9
Address Expiratio Da
U n c no S� a)ist Spri o 'J Telephone 6/13 )731-302— ,
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 0
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 1083.5.1.
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 )c yC J�! �°15��
tr •d
e2I :60 b0 82 unr
, .
•
oaltwrnTo
� `.dejr� � £ (rif).2 of Pa tllumpton
•2' DEPARTME1'IT OP BUILDING INSPECTIONS L --
' 212 Main Street ' Municipal Building
Northampton, Mass. 01060 r
WORKER'S CO\SENSATION t SIT CI AFI'WAVlT
I, - 4=W 1�(UL�'1�� ��T210TDr(G_ i�iP/,AJb7'i�N�
Oi ccnsxJpermi ttcc)
with a principal place of business/residence at:
53 2O U11� n Q rS- Je,s-15prcn c'e(d f'&I (phone::) 613)731-Y0 i'• D--
(strw/a ty/st of p) .010T 7 .
do hereby certify, under the pains and penalties of perjury, that
•
( ) I am an employer providing the following_ worker's compensation coverage for my
etuployces worJng on this job:
/44P-0024500 ( Ala t1 6 g2306 7'73X 6`7560)- /R/40(-/
(Lnstu-nc Com016y) (Polk-: Nu_ r) (Expiration Day.)
( ) I am a sole proprietor, general contractor or homeowner (ccie one) and have hired
the coon-actors listed below who have the following worker's cocpensation policies:
`Nomc of Co:`.t:acto') (InR!ranc: ColnoanyfPotte Nr w bc ) (Exiirauon Datc)
(Name of Contractor) (Lnsarancc Compaav/Polici Namara) (Expiration Date) ,
(Name of Conn-actor) (Insurance Company/Policy Nastu) (Expiration Date)
(Name of Contractor) (Lnsuranc Company/Policy Numb r) (Expiration Datc).
(att .u;j z'ro oral ct if-moo azc)•to mcu�infcxma i oo petniaiag to all �oo -_cos) t
�
( ) I am a sole proprietor and have no one working for me. `
( ) I am.a home owner performing all the work myself.
NOTE:plc.-se bc eon Itlt:N{`JC bomcowocr3 NOo employ pc10[u ld Lk,r-xir]r-^i n., c03:7--:4130 C.rcpair wort of,d..e1L g of
not more tb:.a thro_=kJ io which the bomoowocr rmido or oa the ground zpputcv_r7 tbc-an r_-c not(0early ooezidacd to bc
catploye-a unG-Lb:waeida r n..y----tip Act(GL152"xs 1(5)),applicttioo by a bomcowvc fez:lira.a Fruit rrzy evidmcc the .
legal eta^„of en o=pIoy c under the Worlcoe:Coc ,o iioo Act_
I uo4a-,t nd that a Dopy of thi,ctratccocoa may b.for-Na°,1.d to tbo popertmoot of I,+A'.-rial Acad.:0'OQoo of Loa ua000 for lb.
oovcrasc vgiftcaiioo and th_t fz.amt to aoLZtrc`covc,-o c uodeT soction 23A of MOL 152 cut lad to the i %tioo of a-k ia+l pcnaltio
000saim3 of a fine of up to S 1.500.00 andfor impriyoametn of up to cot year a.od a s.il prtu tun io TSc form of a Stop Work Order and a
fitn of 5100.00 a by ap-inst me
riot dcp.rtm�•t u,e only -
/- 2(�J1oq
Purnbcr
S stun of Lio scc/Pcrmiucc e -- .1