10B-087 (8) r
233 MAIN ST BP-2000-1 165
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B-087 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1165
Project# JS-2000-2048
Est.Cost: $8200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R & H ROOFING 105948
Lot Size(sq.ft.): 9583.20 Owner: FOURNIER ERNEST PHILIP&
Zoning:URB Applicant: R & H ROOFING
AT: 233 MAIN ST
Applicant Address: Phone: Insurance:
1 FERRY ST (413) 527-9378 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:6/21/00 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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 6/21/00 0:00:00 4153 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
• va
--- f: Department use only
City of Northampton Status of Permit:
ii, JUN 2 0 20,00 Building Department Curb Cut/Driveway Permit _
L . _,. . 212 Main Street Sewer/Septic Availability
��Frn_o-,,
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
This section to be completed by office
1.1 Property Address:
4 /
L' A441 'v Map // Z5 Lot 7 i/ Unit
.t` PS,
ill 4- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
_ i
2.1 Owner of Record:
ei)iv, 'ic)L) w if R 9-ss. PM, it/S'fi
Name 'nt) d Curen,�hailing C dress:
Telephone
Signature
2.2 Authorized Agent:
"/1 re-f--s, ?o .3g, -Sons ' 4 d 6 0 • rv61
Name(Print Current Mailing Address: f,r
/ F 1E--W .r
ALm ig
Signature Telephone qi 5 ,- J — ' ?r
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Buildin (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 4//5—3 g)-5—
This Section For Official Use Only
Building Permit Number: 11961) tti91 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4 ,
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 bidg&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 !ems� 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
No
IF YES, describe size, type and location:
e 1
--:TION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 DemolitionD New Signs [ ] Decks [ ] Siding,[ ] Other [ ]
Brief Description of Proposed Work: 1' : MO Vi .f�- ;,�':1'L A-m/0 . �' h.(-- tV Vt/ 0 t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet D
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
edig 0` 1.. bq(3 ," 1!r , as Owner of the subject property
hereby authorize to act on
my behalf, i II m ers relative to rk thorized by this building permit application.
Signa ure of Owner
Date ' C
, 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 perju .
Print Name
Signature of Owner/Agent Date
I SECTION 8 -CONSTRUCTION SERVICES
Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :
License umber
Address Expiration Date
Signature Telephone
Not Applicable 0
Company Name Registration Number
7E� OOc ✓✓�
Address Expir tion.Date
:15.2 7-q31 '��9.41° --
�t����-rt�l�7'elephone�
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.
e'^ned 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 fix you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State an ocal Zoning Laws and e of Massachusetts General Laws Annotated.
— J
Homeowner Signature
"'y -.,.. nj sF+ ,k 3 n q, .... "i v �u«..�.u...�E. A . .. - ..E':
„"`Yi�.�. walk Ir ,. .., � -,� ��, 1 e���.._< � .„.zl__ .t.f�.aR;,���
I. •
oa�tvutp0
a� `_ `E Gill), of Northampton
" •
, .
��:�/ . }�asartchnactta _:
— DEPARTMENT OP BUILDING INSPECTIONS • —
212 Main Street ' Municipal Building
'Northampton, Mass. 01060 r`
WORKER'S COMPENSATION INSURA.NCb, AFFIDAVIT
I,
(liecuscrlpermi ttcx)
• with a principal place of business/residence at: •
— (phone)
• (strl~i/city/stair zip)
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.
WC a 0.0 /,�y2o,D-,
(lnsur-n Coop:myr) (Policy,Number) • (Expiration Dare)
( ) I am a sole proprietor, general contractor or homeowner (cc?e one) and have hired
• the contractors listed below who have the following worker's•coopensadon policies:
(Name of Contactor) (ln uranc Company/Policy NumLYr) (E.pirat:on Date)
(Name of Contractor) (Insurance t ompauy/Poticv Ntumb'r) (Es-pir,:tion Date)
(Name of Contractor) (Instil-anon Company/Policy Ntimbe.r) (Expiration Date)
(Name of Contractor) (Insuranca Compamy/Poticy Number) (Ex-piration Date)
(anath 3d xt,ocal t'xd Jncoe-i,ry to mc,&inform oo pertaining to all oou -..e_on)
•
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pl¢sc be ew-uc dun....Lilo bocnaowxrs wbo cmplay pmsoro to do --.:mim c-repair work oa a dwelling of
not[note thus 1 =its in tt',neh the bomoowocr ratidcs or oa the grouadt appu tcnars tbcdo LT aye gear-.lty eeci:d tt to be
employe,urv'a thc..tixk.cs's oc _tion Act(GL152 1(5)),rpplirition by a bomoowva fora lire_cx{ ,tun n_y evidence the
legal[taro of as cavloyer under tbo Worko(r Coa>eoaation Act
I undQstaad that a copy of Chi,etatcmr>t may be forworderi to tbo Dope,tmcm of Indus/id Atodcati OMoo of L>;ur'000 for the
covm-gc vcrifieuioo and that f_ilurc to soaue oovcragc trader section 25 A of MOL 152 eon Ind to the imposition of mminil penalliea
oocairdag of a rune of up to 51.500.00 and/or of up to mac year end aril pmattio is the form of a Stop Work Order and a
ftta of S 100.00 a thy against me
For dcpanm r uu,c only
Permit Number
__(-h_U o " Map:: Lot
rgnahim of Li )c rim ticc 1- e