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L YLEDGENIEN
V 'T
I Tr,e S o alio-ws t,:e homeowner Le nzLz under 780CNER 10S,-3-4 to
• Mef,7
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It,'C 0 rlS*,7LZ C-LLJ r-' , C, er
-t-,oMdcl;vl
cj2 wiic.-.he!slne res-ides or Lit,---ds to be, a orze or two fmmziy
acct-S-Soly to
such use and lor f?-=,
Iperson C,-,, C coastzu=More tl=, one home=' a SL,2-71 rot be considered a
.home G-,,ner.-
T-f-d f.-F tl:e Civy of Ncrth:::rr r W-,==7 per---cr.(S)who sea: to
be av-
use as r-z L-UCII UWZ:
tLatl by CoL-r::-- so you be--.O=e re-sipor-sible for comp ice with s-tate buEdInz cce'es
and reT22fc ec-,-Zon proci-----
us_ TL--Ls tLat the buEldanO, de--x=ent be cv-lled
to i=- -ce-cl wci at v-,zncuz wEch include found,,tion1foptings rbefore bacIdUA
sr-notub-e holes rbefore Dour). a roue buildinz kis-recdo (before Work is
carxe:gE"=,
ri4-tj4n irzzecti-ag-(if rL-guL-zd)zmiaTma-7 bull dinsa i=ectilon- Tae
b rd I d L--:z d,- n-. Lures th,ess.a=pe-c-6ons before the-work is�nc--J f r o
sure Wiese insLe�z?ans-w�az-- - -.1 z . . 1 -e�,1.ail.0 e t
can result in failure to obtain a cerdffcate of occupancy
Z Al u=,bin= gas) tLe zLe homecwmer c:Her,L=6�-6- n pe:7orm-WOE--c
�-c=ea-wm-- will b e re:sucr-Bible e t o I=cie-s7-,re r ha t-LL e trades hLred SerW e theLF P rcP er'
7'el--ZiTZ Ull C-cr-ju=ori tG tLe building Lissuel-1 a--d that theyclet their required
Laspectious-FaEure cl-FzLe ti-adles to serge the peamizs and in4pe--LlGZs as
ed czz D _T A Y t:He prqjfe u--t- such to:.e as tLe proper pezmhs and LISDeCtiOns are
(�;m- oT6--Iresid,ent2 zaa-ture requesting e: emiptioii)
I Ca:l I to ScLedul-a-TT re-ClUiie-_4 bu;ldizz M- spector-a nt--e--szry for the b uil diz--- Fe
Issued to Ime.
Date
lo-ca-ior
. -^
Office of Investigations
• oR 600 lVashiitg ton Street
Boston, --4 02111
w w.Mass.,goVIVia
NVorkers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
�AI✓ollcant Information Please Print Legibly
Name (Business/Orzanization/Indivi(ivaI): — _
A aA
cZUUr eS$. .
Cite/State/Zip: Phone:
re you an employer? Check the appropriate box: Type of project(required).-
an a employer with 4. ❑ I am a general contractor and I
6. New construction
employees (full and/or part-time). have hired the sub-contractors
❑
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for mein anv capacity. employees and have workers'
9. Building v addition
[No workers' comp. insurance comp. insurance.
❑
irequired.] ❑ ��i e are a corporation and its 10.❑ Electrical repairs or additions
❑ I ant a homeowner doing all work officers have exercised their 11.F7 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per NIGL 12.7 Roof repairs
insurance required.] ' c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
'Amy applicant that checks box Fri must also fil out the section below showing their woricers'compensation policy information.
Ho meowne:s 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- ontractors and state whether or not those entities have
employees. If the sub-centractcrs have employees,the;must provide their wor'ters'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:
Policy r or Self-ins. Lic. b 'tj i'� �b _.Expiration Date: T
Job Site d_(�ress: 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 NIGL c. lit can lead to the imposition of criminal penalties of a
fire up to S 1,500.00 andior one-year imprisonment, as well as civil penalties vi the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
'nvestiatons or the DLk: for insurance coverage verfication.gi
!do here-by ce y urrrt,�, tlse p a rrl rraltie of exjah}tha the information provided above is true and correct
i gnature: Date-
'hone
?:zc L��e...ur1.`. I?u�rtr to�rzlhis_ar_en to be eomaleted bw cin or town ofticiaL
City or Town: PermitlLicense — 1�
lssuing Authority (circle one):
BO'ar� !)I i-e:lli
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superiisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.Registered Home- m r vementC'anftictoe Not Applicable ❑
/// -6r157 g
Company Name Registration Numb/r�q
o ,4 /
Address Expiratio ate
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...... ❑
ge>rnat o
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.
'/elmeowner Signature
t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition F-1 Replacement Window's Alterations) ❑ Roofing ❑
Or Doors r71
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [o] Other
Brief Desr,�iption of Propose /
Work: 19v1_1_i �ttit,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New Ouse antc.br addifiiait to ez stin4`housing,C6iiip fet the`€oIt'dwinq:
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 i 7a--OWNER AUTHORIZATION-TO BE COMPLETED`WHEN`
OWNERS AGENT OR CONTRACTOR 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
1,
/-&l Cl. (��1✓ as Owner/Authorized
Agent hereb declare that the statefrients 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.
n
Print Nam
yr" 7 d
Signature ent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Pr se_d Required by Zoning
This column to be filled in by
Building Department
Lot Size J/
Frontage
Setbacks Front ,V
Side L `1 U....m R _.�.�.. 1 .. LE R.
Rear
Building Height f
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved ��
oarkinir)
#of Parking Spaces
Fill: I
(volume&Location) --
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued::'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page- Document#!
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW C) YES C
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 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 pian
that will disturb over 1 acre? YES n NO
IF YES,then a Northampton Sform Water Management-Permit from the DPW is required.
Depan`rnerrt ttse-only
City of Northampton Status of tle"t-'
!�
Building Department Curd CutllDrewa�rPert
212 Main StreetewerFSephc Rrrarlabtl�ty
Room 100 I aterfWel[Availabdity
s
Northampton, MA 01060 Two Sets of Structural<Plans
PQ� ptighe 13- -1240 Fax 413-587-1272 1?otlslte Plans
k�PLICATiON TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEdTI(K 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: \
J�(:I`� Map Lot Unit
i Zane Overlay District
0/06
Elrri St District C13 District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
'I't 11*46-try✓ IECP"eG•yt�
Nam P ) Current Mailing Addres
Telephone
Signa u
2.2 Authorized Aqlwt.
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ( �I/I j/,_ (/� /^�. J G ,"( (a)Building Permit Fee
2. Electrical (b)Estingated Total Cost of
Construction from(6
3. Plumbing Buildings Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number S--
This Section For Official Use Only
Date
Building Permit Number- Issued:
Signature:
Date
Building Commissionedlnspector o ui mgs
M
File#BP-2008-0868
i
APPLICANT/CONTACT PERSON MCCREARY HEATHER S&
ADDRESS/PHONE AMY L ZEDAKER FLORENCE (413) 586-7832 Q
PROPERTY LOCATION 66 BROOKWOOD DR
MAP 29 PARCEL 390 001 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: INSTALL 24'ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFC�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
4/0 4 0
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.
66 BROOKWOOD DR SP-2008-0868
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 29-390 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-2008-0868
Project# JS-2008-001318
Est. Cost: $5549.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TEDDY BEAR POOLS & SPA
Lot Size(sq. ft.): 10541.52 Owner: MCCREARY HEATHER S&
Applicant. MCCREARY HEATHER S &
AT. 66 BROOK` OOD urn
Applicant Address: Phone: Insurance:
AMY L ZEDAKER (413) 586-7832 O
FLORENCEMA01062 ISSUED ON:411112008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 24' ABOVE GROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: �/0$ House# Foundation:
Driveway Final:
Final: Final: /a$
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rovah: Oil_ Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE Cjjy OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy si nature: '"° r.=! Zg.
FeeType: Date a d: Amount:
Building 4/10/2008 0:00:00 $25.002373
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo