24A-015 (3) 91 PROSPECT AVE BP-2002-0340
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-015 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0340
Project# JS-2002-051 7
Est.Cost: $1918.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 2151 8.64 Owner: SIENKIEWICZ PAULINE A
Zoning:URA Applicant: SIENKIEWICZ PAULINE
AT: 91 PROSPECT AVE
Applicant Address: Phone: Insurance:
49 DREWSEN DR (413) 584-0947 0
FLORENCEMA01062 ISSUED ON:10/1/01 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT ACCESS RAMP TO DECK
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 10/1/01 0:00:00 394 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2002-0340
APPLICANT/CONTACT PERSON SIENKIEWICZ PAULINE Al
ADDRESS/PHONE 49 DREWSEN DR (413)584-0947() / cL
PROPERTY LOCATION 91 PROSPECT AVE �p�p l — 55 !`1
MAP 24A PARCEL 015 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out M` Li�
Fee Paid ��f�('
Typeof Construction: CONSTRUCT ACCESS RAMP TO DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
pproved 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 Comm' i Permit from CB Architecture Committee
/0 �ooy
Signature of Building Officia 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.
Uepartr- nt use on 4•
15) (ra 2 fl (1!1 t.'im• o.f Northampton Status of Permit:
l� l5 q V • ing Department Curb Cut/D�weway Permit
'1 A 2 Main Street Sewer/Septic Availability__._,._
SEP 2 6 2001 Room 100 Water/Well A allability
Nor ampton, MA 01060 Two Sets of Structural Hans
587.1240 Fax 413.587-1.272 Plot/Site Plans
DEPT OF BUILD NG INSPECTIONS
NORTHAMPTON,MA 01060 Other Specify__________
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Pro /ert Addr s:
(� This section to be completed by office
/ ,A)Le .- Map Lot Unit
alb 17/A__ Zone Overlay District
/ v Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1
2.1 Ow 4. of Record: �/ dA
Q Te rda-!` /4. ._.
Name(Pr. ) n r Cu if n Address:
J4' �-cA
Telep one Y/3eY r / )/2
Signature
4 2. Authorized nt% 7Jc)-- e6"4"Y
Name Print .�/ Current ailing Address: 44
/f3/)-- c6 7-53- 6'al 5-15- —',354?
Signature lepho
SECTION 3 - ESTIMATED CONSTRUCTION_COSTS
Item O _ __ Estimated Cost(Dollars) to be Official Use Only
1,p/►7 'I mpleted by permit applicant
1. Building /? /,' (a) Building Permit Fee
. Ele 2c I / (b) Estimated Total Cost of
Construction from (6)
3. Plu g Building Permit Fee
4. Mechani (HVAC)
5. • rotection
•
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 3gt(
, ti- c) --
This Section For Official Use Only
Building Permit Number: "9/2).U7O 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 U / l�
Frontage
Setbacks Front
S /
Side L: R: - L: R:
Rear
Building Height 2
SAtivcr
Bldg. Square Footage /4 /0)
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 V 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 ere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
--- --+- —-
SECTION DESCR " P OPOS4'EilliWO K(cii Ck ] applicable) .,
�kK.,:meNw x...0 .>s w a '1 asz r..,t`,be-d W3 a..,,,,, frem ogo,g,ogo^o n.,e sr+3 Y �i .
,,,Ik„I _,,P,M,M,t .fig 3_x3tVa"vas"».1,..N,. �.'F '.a, �,w �'g.,M . A Org3NaNZP i ,.. a P� aah 11333s
..,ac,, ., *'s,M.. . � ' '.war 3„ ,i. ^4 = 6''.;r, ,.,§ 33 ,,, xS B , .n ;.
New House 0 Addition ❑ Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ]ti gfif Siding[ ] Other [ ]
Brief Description of Proposed Work: A4_ s� * .
Alteration of existing bedroom Yes ✓No / Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
601fINegItib e�I.a I ddition to exi 'til itifig; affird e t elf ll Whit:
a. Use of building : One Family Two Family Other
b. Num of rooms in each family unit: Number of Bathrooms
c. Is there a ga a attached?
d. Proposed Square foo ,�of�new construction. Dimensions
e. Number of stories?
f. Method of heating? N,\ 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 I
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 ENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Owner of the subject proper
hereby authorize to act
my etVf, in all ma ers re ive to work authorized by this building permit application.
Signature of Owner Date
?4 cza.e.....6rte: .
, as Owner/Authorized Agent
hereby declare that the statements and informatio n the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name \ 1
l
Signature of Owner/Agent Date
•
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 1/
Name of License Holder :
License Number
Address Expiration Date.
Signature Telephone
ma: v me t ont". "'a " • r; ;, A Not Applicable 11
Company Name • Registration Number
Addres Expiration Date
elephone 10�7 ` Slc-Y6
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 affidE
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No 0
ome,Owne LLxempti n'
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
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
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, Sta nd Local Zoning ws and State.Qf Massachusetts General Laws Annotated.
Homeowner Signature
._ .‘
Q.'CtpTO
9 A� :1;
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a 5- wit R# Alassschnsetts' r .
miyikla-
W y DEPARTMENT OF BUILDITIG INSPECTIONS i ��
•
212 Main Street ' Municipal Building
Northampton, Mass. 01060 so'�•y
WORKER'S COMPENSATION INSURANCE AI+'lt'1DAVIT
17
(licensee/permittee)
•
with a principal place of business/residence at:
4,
(phone#)
(btir_et/city/star ip)
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)
if.
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sleet if nece,,,ry to include information pertaining to all ocatractors)
(✓/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 homeowners who employ pawn:to do tnainrr,,, ion or repair work on a dwelling of
not more than three units in which the homeov,mer resides or on the grounds appurtenant thereto are not cenc..d.ly ooasidcred to be
employers under the worker's compensation Act(GL152,.m1(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Workees Compensation Act..
I uncle:mould that a copy of this ctatemmt may be forwarded to the Department of Industrial Accident.,'Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S 1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Ord .-and a '.
fins of S100.00 a day against me.
For departmental rrao only
t X "7.1-1'6°71 -... ,--.4
Permit Number
Map# Lot#
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SEP262001 !
l -- 1DEa10F BUILDING INSPECTIONS
NOR?HAMPTON,MA 01060 vrj
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