29-298 tt/J f PT
O e
-
B B �Tassncfinsctta' z
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFrMAVTr
1, —
(licenserJpermitiec) — --
with a principal place of business/residence at:
(phone#)
(str-c,t/ci ty/staLehi p)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the followng worker's compensation coverage t")r my
employees working on this job:
(ln_su oc Company) (Policy Number) (Expiration Date)
O 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)
+r
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F-\Tiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(attach additiomd ilxet Lf necus_+.ry to inchuie inforrnrtion periniuing to e11 c aradots)
I am a sole proprietor and have no one worEng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that�vhilo h0mcow1xr3 who cmplay pcaom to oxrst u —or repair work as a dhstlliag of
not nxx'c than thrro units in which the hoIISroavcr resides or on the grounds apputtcnttni thacto ere oot gcncrally cocnidacd to be
employers under tho wack&s ccttr cation Act(GL152-"1(5)),application by a homcowncr for a liccose cc permit may cvidcaoc the
legal antic of an employee under tho Wo koet Compemation AcL
I understand thrt a copy of this e**tcmca+m,y bo forwardod to tho Dcpermrni of L>d sL rial Au i&ni&Ofiioo of 1mru":'O for the
coves tg vrrificaiioc and that failure to secure covccago urZc:r soctioa 25A of MOL 152 can lead to the imposition of criminal penalties
oomistiag of a fine of up to S1,500.00 andloc imprisoumrnt of up to om year and civil pcualtia in the form of a stop Wmt Ord,—and a
fum of 5100.00 a day 1&kinst M
For delu�uao oaty
permit Number
Lot#
?4 iamb—Ire 0 t ermitlee
, 1 s •
SECTION 8-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
w,,,,,�S
Not Applicable ❑
,s f ed m e �vm ,2 I„ ,
Company Name Registration Number
q YA 1"s - LJ AJCA Cfi ” 06'sk6 l( t30 � C�Z
Address Expiration Date
l-1(- Telephone 3
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...... ❑
W poi Wee, one a � i n
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(checkrall applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [/] Siding [ ] Other [ ]
Brief Description of Proposed Work: �9 S/alb
Alteration of existing bedroom Yes—4— No Adding new bedroom Yes _ No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a If Ne house a id.or addition to:ezist'ing.housing complete the:follawihk:
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'Adkkt OwCONTRACTOR APPLIES FOR BUILDING PERMIT'
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
ff7_ 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.
C2
Print Name
oz
Signature o Owner/Agent 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
=ation)
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 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 there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
City of Northampton o
----�;--- Department
_ 2 fain Street Se eC e -I
!1069m 100
N rth on, MA 01060 7 eta ,
vhol�e -5$ 40 Fax 413-587-1272 PaISitePla a
OfihertSpeclfy '°
APFL{GT}kOhT4�sQFJ �RUCT, LTER, 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:
C/4C/1-C Map' Lot
fJDt 5�� = unit
/C v
Zone OverIa District
y
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature _
2.2 Authorized Agent:
ka: C�c� le's _,L l ( �' RoG�✓ C/ 06sl6
Name(Print) Current Maifing Address:
3 � �yvl' 7 - —
Signature Telephone
SECTION 3 -'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building ��� (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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-1071
APPLICANT/CONTACT PERSON MARIO LARA
ADDRESS/PHONE 99 YATES ST (203)389-1467
PROPERTY LOCATION 128 BROOKSIDE CIR
MAP 29 PARCEL 298 001 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
Typeof Construction: REPLACE FRONT&SIDE DOORS-FIRE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 569853
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 o ssion
00 2_—
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.
. .. '
-1071
BP 2002
41r+,
czl�#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-1071
Project# JS-2002.1671
Est.Cost: $200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARIO LARA 569853
Lot Size(sa.ft.): 20473.20 Owner: LARA MARIO
Zoning:URA Applicant: MARIO LARA
AT. 128 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
99 YATES ST (203) 389-1467
W HAVENCT06516 ISSUED ON:616102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT & SIDE DOORS FIRE
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: 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 6/6/02 0:00:00 MO $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo