23D-198 (3) Y \
53 HINCKLEY ST BP-2000-0927
GIS#: COMMONWEALTH OF MASSACHUSETTS
vlap:Block:23D- 198 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-0927
Project# JS-2000-1708
Est.Cost: $1200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 13939.20 Owner: DUCLOS JOSEPH&DEANNE DELISLE-DUCLOS
Zoning: URB Applicant: DUCLOS JOSEPH & DEANNE DELISLE-DUCLOS
AT: 53 HINCKLEY ST
Applicant Address: Phone: Insurance:
53 HINCKLEY ST (413) 586-6069 ()
FLORENCEMA01062 ISSUED ON::9/25/00 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector 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 0:00:00 555 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
1
LAE-de-1
51L/t/ pi,t/15
ti
Department 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 01060 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
Map
1.1 Property Address:
I—)i e.l�l�i( s-i This section to be completed by office
23 D Lot I -f t D Unit
.�3 n�
fe9/0 b Zone � ��'" Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
c ,oS s 3/7'Nc 1/6, s7/-4e e_ /"la
"-me(Print) Current Mailing A6 6c)th 7 C,(d G`)_
Telephone �S
Si e
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 J a�� (a) Building Permit Fee
\ you
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 j 5 •�
This Section For Official Use Only
Ruilding Permit Number: F3Pci)9a-7 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 DK 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 k
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
Nod
IF YES, describe size, type and location:
CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
yBrief Description of Proposed Work: �E (,� Tt_C S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ . Sheet❑
6a. If New holtite4and.oMirditiOitto'e* g 1ousing.I'Comte e e foll{)1l4lrl :
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
, 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
here c e that t e statements and information on the foregoing application are true and accurate, to the best of my
kn edg and belief.
igned under the pains and penalties of perjury.
Print Name
y—.%'42�% cue
Si r Owner/Agent Date
SFCTION 8-CONSTRUCTION SERVICES
L Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9. Registered.Home IFnlirtty r�i�an#EEO€>n ri t r: ,� s � _._;x; r .;' €.`` Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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 0 No 0
=..-� oraellwrierittemiitton
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 Zon' w and State of Massachusetts General Laws Annotated.
Homeowner Signature ���
e
�° (riff of Northampton =
_vvE 545anclincctta _=
DEPARTMEUT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building •
Northampton, Mass. 01060
WORKERS COMTENSATION fNSURANCE ArrIJAVIT
(Boons:Jpermittcc)
with a principal place of business/residence at:
hone:'
(stet/ci t J/sta tcrzi p)
do hereby certify, under the pains and penalties of perjury, :hat
( ) I am an employer providing the following worker's compensation coverage ge for my
employees working on this job
(Insu_rancn Company) (Polio Number) (11.xpirtion Date)
I am a sole proprietor, general coniractor r homeowv r CLrcle one) z_nd have hired
the contractors listed below who have the foilow,ng worker's compensation policies:
(Name of Contractor) (insurance CompanyiPoiic; Number) (1-ix:puauon 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 additicc l shoes ifnoe—ssry to ane'u&infoco o°portairing to all oocraco:3)
( ) I am a sole proprietor and have no one working for me.
Ap<ram a home owner performing all the work myself.
NOTE:plcso be aware that wbi)o bomcowncn wbo employ pc.•rom to do tr.irsrri+orr coatsuaioo err repair work on a d.will_g of
not mocc than tbroo units in which the boc000wner resides oc on the grounds rtrpurtensni thccto arc oat eco rally coerdaed to be
employm urx&cr the wtxkri's cs..p,—sc-lion Act(GLI52„s3I(5)),application by a homeowner fare licx or permit may cvidmcc the
legs)statue of an employe(under the Wodc.or'a Coccpooaatioa Act
I underoraad that a copy of thu chtemrco may be forwordnd to the Dopartmeaa of l.oehas:rial Aoadmsa'OfLoo of k w-a000 for the
coverage waif calico and that Lilure to secure coverage under section 25A of Ma-152 cm lead to tbo imposition of aimiasl penalties
000siuing of a floe of up to S 1.500.00 and/or in:Fa isoamem of up to one year and civil pcnattic3 in the form of a Stop Work Order and a
rum 0(5100.00 a day against me
For M.,.,.,e l we only
Permit Nwnber
lvtap:" Lot "
gnatarc of LiccsaseriPccmittcc Date - _