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29-251 The Commonwealth of Massachusetts Department of Industrial Accidents == _ ; Office of Investigations 1 .- - , 600 Washington Street '� -r Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): !7r s -e/'� �l'2 A2 Address: 5 6;--c/( U,-'r at City /State /Zip: f AO d_3 /Phone #: y /5 } C -/0.5- Are u an employer? Chetk the appropriate box: 1 I am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. 111 I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition workin for me in an ca aci employees and have workers' g y p 9. ❑ Building addition [No workers' comp. insurance comp. insurance.. required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. / �J Insurance Company Name: , , f f0Cr.,c .. e ; %c a r'.^ ,f ` a Policy # or Self -ins. Lic. #: jt ' ©3 c' r (° f Va) /O& / 6 Expiration Date: / -, /7 Job Site Address: G / 0 0 r �in.:of iell City /State /Zip: // y ■— c° t / 0 ,6e .4 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certift under the pains an, • , '.s o ' , erjury i the information provided above is true and correct '` Si. ature: .,�� — Date: _ _'f' `/ Phone #: %/3 - .3`Z. C - / S Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: -- . a.mluulis Ino u� M pll OM _ fas ►aaaas,�apun J`�� J 040 dW 'N3QdWdN M81A 3lCaIC 99 j � OMN32I0 3NIW 40/0 1 � `I }• '1 � Y t':. :: i. l:� $ � � 0,91064s AOLI3 • 9I IZ0 'VL1['uotsog :••: OLIS a;lns- uzuld 01 V80 Z1.0l)e,VP ;' :11ol;ugdx3 11 = uoitup►Rau sseuisng pus sJukolf aawnsuoa 3o aajj : ed�Sy L9ZE9�`' :uope►l � r 0 :ol moult pun0J JZ 'a ;up uollualdxa eqi aaojeq 21010t1211NO01N3W3AOHdIN1 a1NOH ' Sia►o asn InplAIP)q PIIUA 1101111.11si2ea .►o asuaal i ►nS V 11 & �0R° "o1+1aat{JO INlassachuM'ttS Bepartu►ent or Public Sat'cl: hoard of Building Regulations and Standard Construction Supervisor Specialty License License: CS SL 99381 Restricted to: WS,IC .•, 3HAEL GREENWOOD 7 ' CIRCLE 1!::.W DRIVE :1AMPDE:•: MA 0'10 Expiration: 3/9/2012 ' ('uuwlir 4funer '!'r#' 99381 • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : rjg e 99,3j-1 License Number ja - ( .�� «- �� � . 3- /c Addr / 404 0' Expiration Date ignature Telephone 9. Registered L Home Improvement Contractor: Not Applicable ❑ 'r f / e/ti 4 1 Registration n ber Company Name Re 9 Address Expiration Date Telephone ya5 /631 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 buildi g permit. Signed Affidavit Attached Yes No ❑ 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [p] Other [ Work: escri ii �J (' -/, "s r cJ/ %' Ai/ v Ae- or ill Alteration of existing bedroom Yes L-7 Adding new bedroom Yes t/ No Attached Narrative Renovating unfinished basement Yes c_.,..-' No Plans Attached Roll - Sheet 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. Masscheck 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 1 , �///�/.� , j 2 `7 ,C / ' /, 4 - ' as Owner of the subject property / / hereby authorize 7% 4 ,, �e 4 /' ;J� f to act on y behalf, in all matter elative to woradthorize this / building permit application. Signatur of Owne 2 Date - Jr-, 1, / /f r Z'4' fN_ ,' el,i, 4 ,4 J/ , as Owner /Authorized Agent hereby declare that the stat ents a ' formation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. __� / r,4r / / • i Prin /'' Signature of Owner /Ag- Date Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 /Findin ever been issued for /on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0 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 0 NO e IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO / de IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ((it of Yarn s s , - S1'tttssttriTusetts * L DEPARTMENT OF BUILDING INSPECTIONS ; 212 Main Street • Municipal Building � �� Northampton, MA 01060 LOUIS INSPECTOR BUILDING PERMIT FEES Phone: (413) 587 -1240 BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413) 587 -1272 DEMOLITION $ 20.00 ACCESSORY STRUCTURE $ 35.00 PRINCIPAL BUILDING — Residential $200.00 PRINCIPAL BUILDING - Commercial *NEW CONSTRUCTION $ .50 per square foot for 1 floor .30 " " " 2 floor .20 " " ' /zfloors, attic, basement, garage STRUCTURAL ALTERATIONS IN ALL USE GROUPS $6.00 per thousand dollars of estimated cost or fraction thereof, with a minimum fee of $55.00 $25.00 WOODBURNING STOVE *NEW ACCESSORY STRUCTURES one hundred twenty (120) square feet and over $ .20 per square foot with a minimum fee of $25.00 *NEW ACCESSORY STRUCTURES under one hundred twenty (120) square feet $25.00 per inspection *SWIMMING POOLS $30.00 for above ground $60.00 for in-ground *SIGNS & AWNINGS $30.00 *DECKS $50.00 REPLACEMENT WINDOWS $35.00 SIDING & ROOFING Residential $35.00 per structure Commercial $55.00 min. per structure OR $6 /K of estimated cost TENTS $25.00 *ZONING REQUEST FORMS $15.00 (includes home occupation registration) REISSUE OF LOST PERMIT $25.00 CERTIFICATE OF ANNUAL INSP. $100.00 (minimum) Temporary Certificate of Occupancy $25.00 PERMITS REQUIRING ONLY 1 (1) INSPECTION WILL BE A MINIMUM OF $25.00; ALL OTHERS WILL HAVE A $50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton AND SUBMITTED, WITH THE COMPLETED PERMIT APPLICATION, TO THE OFFICE OF THE BUILDING INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE. !I NO CASH - CHECKS OR MONEY ORDERS ONLY !! * Filing deadline is 12:00 pm (noon) on Wednesday. l 1 Department use only City of Northampton Status of Permit Building Department Curb Cut%Dnyeway Permit 212 Main Street Sewer /Septic °Availability Room 100 Water/U1/ell Aualabi�ly' Northampton, MA 01060 Tw`a Se s bf Stiucturaf Rlans , 171' phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Slte Tans 1 Other Specify R ; 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 6/ av //, Map Lot Unit C Y A4 ' /® 6.4 Zone Overlay District Elm St. District CB District SECTION 2' PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owne.o ftec•rd: .1/Zi L/ Mi lay (11 r/�0`� I)riv� F / ors Name � Curre A dres � ,q,�, /� ..� �/ Tele Signature / 2.2 Au. • ent: • . - r't� 5`3 `fi � (1� i�r /sir A ► 0 1 44 - J n Current Mailing Address: T e ti LLIIIIE 5/J /c.) Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee /SG® c�G 2. Electrical (b) Estimated Total Cost of A )Z4 Construction from (6) 3. Plumbing S A Building Permit Fee OV 4. Mechanical (HVAC) /fj 5. Fire Protection /1 6. Total = (1 + 2 + 3 + 4 + 5) / 5 c "" Check Number ✓j �c 5 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0183 APPLICANT /CONTACT PERSON THE ENERGY SPECIALISTS ADDRESS /PHONE 55 CIRCLE VIEW DR HAMPDEN (413) 566 -1058 PROPERTY LOCATION 61 OVERLOOK DR MAP 29 PARCEL 251 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 7 1 W �� Fee Paid � Typeof Construction: ADD ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 99381 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Commission Permit DPW Storm Water Management Demolition Delay ekY/i/ Signature of Building 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. 61 OVERLOOK DR BP- 2012 -0183 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 251 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0183 Project # JS- 2012- 000282 Est. Cost: $1500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THE ENERGY SPECIALISTS99381 Lot Size(sq. ft.): 18120.96 Owner: MCMILLAN MISTY V Zoning: URA(100) / /WSP Applicant: THE ENERGY SPECIALISTS AT: 61 OVERLOOK DR Applicant Address: Phone: Insurance: 55 CIRCLE VIEW DR (413) 566 -1058 WC HAM P D E N MAO 1036 ISSUED ON: 8/25/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD ATTIC INSULATION 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: FeeType: Date Paid: Amount: Building 8/25/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner j,10 \ A oaoi Oa\ • HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations The inspection proces_srequires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill). sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper _p .ts- in_conj unction. -to- the- building.permitissued,_and_ they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made ( J ;ii vtI understand the above. (Ho hi. owne /r si • ent s signature requesting exemption) I will c to sc -dule all required building inspections necessary for the building permit issued to me. Address of work bi (0 t & location �1' (1C. n\ r b - • The Commonwealth of Massachusetts Department of Industrial Accidents I� ; ' Office of Investigations • k - ; 600 Washin Street • o Boston, MA 02111 www.massgov /dia IIIIIII -Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individnn1): fI.Sly 0 g e f $96. Address: ( / OU-Y'. / outer df cloveki ce file( 0106 City /State /Zig: Phone #: '1!3 7 e 2 e Are you an employer? Check the appropriate box: Type of project (required): i 1.0 I am a employer with 4. 01 1 am a general contractor and I 6. 0 New construction employees (full and/or part- time).* have hired the sub- contractors listed on the attached sheet. 7. 0 2. ❑ I am a sole proprietor or partner- Remodeling ship and have. no employees These sub - contractors have g. 0 Deniol ion working for me in an capacity. employees and have workers' working Y P ty 9. 0 Building addition [No workers' comp. insurance comp._insutanrpa 5. We are a corporation and its 10.0 Electrical repairs or additions 3. am a �emeo-wner deiag l we lc — _ of�ce�s�av �zs � laei� —1-1. 0 Plutoliing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c: 152, §1(4), and we have no `` d employees. [No workers' 13.ROther 5 h e comp. insurance required] "Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit: indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such_ :Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees; they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. #: Expiration Date: - Job Site Address: City /State/Zip:' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. 1 e advised that a copy of this statement may forwarded to the Office of Investigations of re DIA for insurance coverage verification I do hereby • un' the , , and pe, aloes of perju hat the mforrnadnn provided above rue -ar correct __- _ Siena e: r / i "14" .Bate, r Z5 " { Phone #: - 7! - _ III Offei l use only. Do not write in this area, to. be campfeted by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): -L. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector____ 6.Other = Contact Person: Phone #: i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9.:Recistered Home hnpixiy rnent ntra ©r ,A. _ 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 ❑ No ❑ � .; a ; t, i . '. i s lla: , The_ curt- ent_exemption for "homeow_ners" was ?xten 1erl 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 "homeo er" c •'fies and assumes esponsibility for compliance with the State Building Code, City of • _ ,. ... . -_ cal - Laws - Annotated. " amptori . e r mance ` �� y . • Z - �. - . .. ./ I Homeowner Signat • / � jig jIW 4 .„- ( . SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. lI Demolition ❑ New Signs [p] Decks [C] Siding [p] Other [p] Brief Descripth E of proposed S C� 1 Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet qa. lf. Neva - houseatid-or ad itio =to'existiric h comp lets Elie <folto niifm: 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. Masscheck 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, Lidi .04 _ . �/ / 7 , as Owner of the subject pro - rty hereby authorize r �r ?� to - M .� t b- -all, in - m_tt rs r lath to work aufhonzed by this building permit application. /W!A! /941040/ S'• naturi M r ` Date 1, , 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 Name Signature of Owner /Agent Date y Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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: !_�l._... 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 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page; , and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued C. Do any signs exist on the property? YES 0 NO�� IF YES, describe size, type and location: D: ire There any proposed c ranges to or a`dat o oa'signs intend the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. `f , , 3epart€rxitt • � a � 'City of Northampton Stag of Pe Building Department urtCu��±ewa Fercni� 212 Main Street seiiv�attu��� Room 100 S litll C Northampton, MA 01060 oicesets.of t ns phone 413 -587 -1240 Fax 413 - 587 -1272 ,Rt), 5tt i:'latis " `,, 7 Qttte> Speer APPLICATION TO EONSTRUCT, 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 6 ©verio©k Map Lot Unit Q�reY) G e IAA o ) 06 Zone Overlay District ElrnSt. District CB District SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: a edlock drs f trevitP A/4 b j?6 z Na Sri' / ' Currrgnt Mailing Addre ' ,' ■ . l/ iI Telephone l on 7 C 6 • Si , nature _ 2.2 Aut /zed A. e : 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 700 ®� (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 � A� 6. Total = (1 + 2 + 3 + 4 + 5) Check Number // l v.,►( This Section for Official se Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0215 APPLICANT /CONTACT PERSON EASTMAN MISTY V ADDRESS /PHONE 61 OVERLOOK DR FLORENCE (413) 727 -8065 0 PROPERTY LOCATION 61 OVERLOOK DR MAP 29 PARCEL 251 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 1/3/ 1 a✓ ✓ Typeof Construction: ERECT 10 X 10 SHED 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 OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF R MATION 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 Commission _ Permit DPW Storm Water Management Demolition Delay _ , w f; ��fo Signature of Building 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. * Varian 2es are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Plannin■2 & Development for more information. #I� . BP- 2010 -0215 GIS #: COMMONWEALTH OF MASSACHUSETTS a 1 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0215 Project # JS- 2010 - 000268 Est. Cost: $700.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 18120.96 Owner: EASTMAN MISTY V Zoning: URA(100) / /WSP Applicant: EASTMAN MISTY V AT: 61 OVERLOOK DR Applicant Address: Phone: Insurance: 61 OVERLOOK DR (413) 727 -8065 0 FLORENCEMA01062 ISSUED ON:8/28/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: ERECT 10 X 10 SHED 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: FeeType: Date Paid: Amount: Building 8/28/2009 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo