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23A-022 (7)
21 PARK ST BP-2001-1097 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23A-022 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofmg BUILDING PERMI Permit# BP-2001-1097 Project# JS-2001-1931 Est.Cost:$6100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 10802.88 Owner: PLATT CONSTANCE A Zoning: URB Applicant: Jesse Montgomery AT: 21 PARK ST Applicant Address: Phone: Insurance: 46 Oak Street (413) 585-8482 () FLORENCEMA01062 ISSUED ON:6/25/01 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP, 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 Underground: Service: Meter: Footings: Rough: Rough: House 4 Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: IRough: Oil: Insulation: Final: Smoke: Final:0/c• 7.-/7.01 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON PON VIOLATIO OF ANY OF ITS RULES AND REGULATIONS. ' ..r --. t--ieei Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/25/01 0:00:00 1 004 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo City of Northampton 4 - Building Department a, 212 Main Street Ser�eriSep"s Room 100 Water/Well*Availaill , . - •'" 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 1.1 Property Address: This section to be completed by office l P k Cj Map Lot Unit noPenCe ("AA. (9/o6a Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT .1 Owner of Record: C onnie Pic Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Nam Print) Current Mailing Address: Sign ure Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by permit applicant 1. Building �4`Gi / 0 0 (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) C / OG Check Number This Section For Official Use Only Building 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/Find' g 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. Ark there any proposed changes to or additions of signs intended for the property ?YES No 4 IF YES, describe size, type and location: SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition 0 Replacement Windows Alteration(s) ❑ Roofing AI Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: ��f'i1J J Lay i.lr4 1 iv wood (,✓here nec6c3 ,i.r'ti.� /,,t/,S It Alteration of existing bedroom Yes No Adding new b(5111 edroom Yes / No Attached Narrative❑ Renovating unfinished basement Yes ✓No Plans Attached Roll o - Sheet [7 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? 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. Print N� Signat a of Owner A n ate SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /� Not Applicable 0 Name of License Holder: 3 3 t C lon ems' C S 077 - 1 c7 License Number _Oa K E } . ç• creric c ►1 5 . 0/062 j Jb/ 3 Addr s Expiration ate Signat re Telephone *Nter r i `r m r vemen Contractor ;.: _.,, ..';! „ ," •,, Not Applicable ❑ 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. Signed Affidavit Attached Yes 0 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 ..,it pi. 9 9 f fl O.Lxt I NIrflaniph n _*=r 9•%��1 �% 1(��B glassadinsctla' _"—s '_— =� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 `'�� WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, �e55e C Nl cAe urvl<'w (liff) with a principal place of business/residence at: b Oct K G. - P!Deer( . nil °l o62 (phone#) ,s--0 .5 -eL/e). (bti eet/ci ty/s tat e/n p) 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 Nurubcr) (Expiration 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 ''octal sheet ifnrc,,nry to include information pertaining to all ooatmctors) ( I am a sole proprietor and have no one working for me. i ( ) I am a home owner performing all the work myself NOTE:please be aware that while homcowncr who eruplay persona to do te-.4-rt.-+„ construction or repair work on a dwelling of not more than three units in which the homoowncr resides or on the grounds appurtenant thereto arc no<gcrxrally considered to be employers under the worker's compensation Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Worker's Compomation Act I understand that a copy of this rr,t.-„v+,r may bo forwarded to the Department of Industrial Aocidmti Office of Insurance for the coverage verification and that failure to segue coverago under section 25A of MOL 152 can lead to the imposition of criminal penalties oomisting of a.fine of up to S1,300.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Ord r and a fine of 51o0.00 a day against tee. Foe departnnece 1 use only n y ©/ t Number Lot# Si _ fa(/ l ermittee 6 _ �Y PROPOSAL alliMINIMM PROPOSAL NO. SHEET NO. DATE PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAM t OY\��2 \ \c, ADDRESS @ 1 PA K I ADDRESS a> Q-tv- 1< SA Sec 4" "Et c(f rt c e /'1.4) 0 I O 6 DATE OF PLANS PHONE NO. ARCHITECT j f l 7 We hereby propose to furnish the materials and perform the labor necessary for the completion of r e' / /1/t�-t— f 1, �0 T ' r- S et( rc L.4 cc 1---, ),...t S ;� :r1 Cs �. p /' �-'th \ r^ -v- c.. et)p t- n,-)C.< 4-atc.- 1 I III/Do Sq.. icy; J r- _ ��+ J5 C K 1 j I--t rrt racro" .il i u Yl_ Cor, j-I-5O L ot i. er,�r'Yl J S'� idf si--r i e—W G r r-"lc/ 57'd a 7 4-A-I 5---;i'1C 1QLk3-1.cl h P \ -\\, ;V\S :� - . b.f Cr 1l u..( e -1-a :., c r ¢r f— 4Jr°c�--, Tc� -t ucri�^ bc(nc,e we / l b� vsed a � evrc aAu e • / v/i✓1 ,, , vr&.` te' s. .rtp--iof r Lrr)CA�.t,_ (-co +-- L..1I1ef t_ ;E _ I Pe')Ci i :c -\ f Le.,. . ,_ '-i11car,. 31 y� i 7st a pa c- C1`( p,e V \,n al over' q,rca,S we wi ( .1.5� ,4-1,iol f` U 0 c,1% , _e ti .vt 1 t iy. 1r7s-tLt t f eq L., 0P' dvrcc - ., 7 ctra oLyv c- t.-v ,' I I, y rrecesc .-' 4c d/, Li ,P�fel `i'r1C`!Gf /1P 'f� ! kl All material is guaranteed to be as specified, and the above work to be performed in accordance with.the drawings,and speci cations submitted for above work and completed in a substantial workmanlike manner for the sum of . . I V 7 h::tom;-.r -,L�- - v-\_:n6(rect rQ 0 l i u r5 Dollars ($ 4 _,6/ /(17)() with payments to be made as follows. V 4,+ s�,.0 4. v.. 3 i r�ct,1c -i(..r-t ` .. s/ r Respectfully submitted b X•6:„)/ c7i , � \ o r'=/� k / Any alteration or deviation from above specifications involving extra costs ', . _ ^r will be executed only upon written order, and will become an extra charge Per ✓ over and above the estimate. All agreements contingent upon strikes, ac- - cidents,or delays tleyond our control. Note—This proposal may be withdraw •,etrt:.77.-1,1 1.4n. . by us if not accepted within day • t ; ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the wo' as specified. Payments will be made as outlined above. Signature Date Signature rAdams NC 3818-50 PROPOSAL MADE IN USA