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24A-031 (4) 9 DLACADERRY LANE BP-2003-1041 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A-031 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: renovation BUILDING PERMIT Permit# BP-2003-1041 Project# JS-2003-1217 Est. Cost: $101000.00 Fee: $505.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ACTION FIRE RESTORATION 074416 Lot Size(sq. ft.): 19122.84 Owner: LANDIS ALBERT B &ETHEL G Zoning: URA Applicant: ACTION FIRE RESTORATION AT: 9 bLACKBERR?' LANE Applicant Address: Phone: Insurance: 30 HAYES CIRC (413) 594-7800 Workers Compensation CHICOPEEMA01020 ISSUED ON:5/22/03 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR INTERIOR HOUSE FROM WATER DAMAGE 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:W/56 i Final:,M a 3 Rough Frame: 0 it 6-- PP "(IF. Fireplace/Chimney: Gas: � -' Fire Department P Y: Rough: Oil: Insulation: D k 5 - p7 ..147, Final: f Smoke: Final: dk 7 15• 3 4L THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO jION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Receipt No: Date Paid: Check No: .Amount: Building 5/22/03 0:00:00 52479 $505.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo B *may pT Plumbing Building ❑ Electrical ❑ viAlth® City of Northampton BUILDING INSPECTION LABEL APP OVED Inspector At i Date -114 File#BP-2003-1041 APPLICANT/CONTACT PERSON ACTION FIRE RESTORATION ADDRESS/PHONE 30 HAYES CIRC (413)594-7800 PROPERTY LOCATION 9 BLACKBERRY LANE MAP 24A PARCEL 031 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 562 7 5' icSv 3--Typeof Construction: REPAIR INTERIOR HOUSE FROM WATER DAMAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074416 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFMATION PRESENTED: Approved 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 uilding 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. • 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 MAY 2 This section to be completed by office 1.1 Property Address: 4 'ELlt. t l E Map Lot Unit N1c ityy\ MASS Zone 'Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 6efv..3ortA GocJ LC CV •ame(Printer Current Mailtn Addr g[l S 5 Telephone --l1(( Signkurere (� � \J 2.2 Authorized Agent: _ A'V►0N � ToZ�TI *\) 3 0 ,r-c4 CA-a- U (A reset I/n�, v t4 N.46 Print) Current Mailing Address: W 613- 514—78o0 Sig naa v Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ,30 .1(10 (a) Building Permit Fee s ev. IN (a00. e 2. Electrical (b) Estimated Total Cost of ��. Co S�aD Construction from (6) 3. Plumbing h Do . Building Permit Fee tre 4. Mechanical (HVAC) 5. Fire Protection L 001, 6. Total = (1 + 2 + 3 + 4 + 5) 4if/'DI- ODD Check Number This Section For Official Use Only Building Permit Number: a3-111/ Date Issued: Signature: Building Commissioner/Inspector of Buildings Date . 4 ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing 0 Or Doors 0 Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other Brief Description of Proposed Work: FG�.,c ZII�41112 1, O Houma ©u *o �2 1)�"t KrE Alteration of existing bedroom Yes 1X No Adding new bedroom Yes Y. No Attached Narrative❑ Renovating unfinished basement Yes X No Plans Attached Roll ❑ • Sheet❑ Wl to louse aid or:addition`te Mato .c_ ® Li . -the folio a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: `p Number of Bathrooms c. Is there a garage attached? d VV d. Proposed Square footage of new construction. — Dimensions e. Number of stories? f. Method of heating? v P . L IN • Fireplaces o oyes 0 Number of each I g. Energy Conservation Compliance. kr4 Mascheck Energy Compliance form attached? in . 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 67 Fr k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank* City Sewer Private well City water Supply x SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT SG}t7D1 Ocr-A , as Owner of the subject property hereby authorize i W 4 t It ZO'N) to act on my behalf, in all matters relatiVe ork authorized by this building permit application. Signature of Owner Date I, '�D_vn -I `F 4 //k- / srac Ai ,-�ae-evv��er/Authorized Agent hereby de�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. Print Name , 1 41z0/9.9 Signatu • of Owner gent 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 y( or ore. . Frontage r145 Setbacks Front Side L: R: L: R: Rear Building Height 1 YZ STaiLy S Bldg. Square Footage (. {0-9-- Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces 2- 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. x 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 l� IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property?YES Noy IF YES, describe size, type and location: 1 e .CTION 8 CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: , Not Applicable ❑ Name of License Holder : CTIA.9L1! ' d(1.1/4)^tiA‘4..- b, yy lb License Number J 4l (i ►n.v�c - 5r IN1Ncu.rc,L a � Cr 6 VA 0 '(t8 Io I Addres Expiration Date 594—/%0° Signature Telephone Not Applicable ❑ -ken -re& naQ.4Z Z ./ / / 28! Z Company Name Registration Number 30 'l".e4 Crr2 chrome ot pe. cf(z7/oc Address Expiration Date Telephone �3' 'i*".?6'°O 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. "igned Affidavit Attached Yes X No 0 1n ' ,.n� x, 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 The Commonwealth of Massachusetts _ _^ ( b Department of Industrial Accidents lk _� • Office of/nsesligatfons _4_! -14,,39 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit •\'1')1t'<ult-:'lit l'F'ii(tbrod'' (..Ea , '`'>t l (.:-1E1 name: .)il . DF.i rt.{'I , —r c -O51` C.. : A1)A r B :oil /`; P_ �G f f 4 1e., 'C 4 -t 0,-t is/location: tS d . y ii f 3 2 c [ f city l , 2, G1� - 0 1 0 r L) phone# 11/.3" SS E/ "7 P 6 0 I am a homeowner pirforming all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. ( company name: YYI. €wt..6s " -r- k e) $ti i.4,r, )A 1T 1C\zTv. 2tc H F YZ r -r c> , -, address: ( n ?L t i.,.€S l ii'e t, l e e /n� `f F ,f}- 01 e) city: �.l'i�! .}�0 Phone#: :. � l S _5'`! e/' insurance co. Fit E Yr�-o Zi1c)u^i-rr2rf 01 ►A 4f rvi 1u sti. policy# "d 6 14, v - 1 O I am a sole proprietor,general contractor,or homeowner(circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone# insurance core policy# company name: address. city: phone#: insurance co. policy# 11 L"..r: 1.01.1 L n: t:,t x>:_i:; Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against mc. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true andcorrect. l 103 Signature ii_.-�---C,` ?' 1 �►�` Date _ ` > Print name L�u 4� l& ,174 / / Phone# tl i 3 . - 'V 7reo official use only do not write in this area to be completed by city or town official city or town: permit/license# Building Department .: Licensing Board ❑check if immediate response is required ❑Selectmen's Office fi ❑Health Department ' contact person: phone tit pother :. 'd It (revised 3/9S PM) 94 ealzman+ueald n ll • wM,. BOARD OF BUILDING REGULATIONS -; ' • License: CONSTRUCTION SUPERVISOR • • Number: CS 074416 • Birthdate: 09/18/1956 Expires: 09/18/2004 Tr.no: 900 Restricted: 00 GARY W BRUNELLE 47 TANNER STD—4o!P'`"" MANCHESTER, CT 06040 N Administrator • -67owymonaieaaail a Board of Building Regulations and Standards CcLicense or registration valid for individul use only 4-mi_ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 112812 Board of Building �'' Regulations and Standards �� One Ashburton Place Rm 1301 Expiration: 4/27/2005 Boston,Ma.02108 Type: DBA ACTION FIRE RESTORATION DIANE SWAYGER 30 HAYNES CIR l7 di/4 CHICOPEE,MA 01020 Administrator Not valid withou ature