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29-390 (3) 41 IZ5) O 4A - e ` �j IvJ-f pT (\ arc a��ti� (riff of kirrffjallipfoil E a3aachncctl0' DEPARTMENT OP DUILDD,\)C INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 %vOIUCEIZ'S CO),MENSA710N LNSUR .NCE A II'IIIT)A%TI-J' (li a:nsaJperm;ttcc) v,rlth a principal place of buS;t)tssJrCSidcllce at: Ir ho n c-') = 7 / (so txt/rci ty/s=- C-/:6P) do hereby certify, under the ppins and penalties of perJury, :hat { ) I am an employer providing the following worker's coinocnsadon cove Ige for Ind' eluplovecs worlring On tills job: (Ins�tr_a Corer s�) (Peke,- Number) --- (t=.-pIr-,do n Dai) O I.a_m a sole proprietor, general contractor or homeowner (cu cte or?e) zoo hive hued the cone actors fisted below wbo have the foilo%ving workers G0c--2;)eILs26on policies: (Name 01. COnt:nGiO') (InRr3nc"c C0rIID1n)-rPOUc-, Datc) (Name of COnQZ!Cior) (L is-waacz CoJmoanviPolin, Number) (Expu:oon Date) (Na-me of Contractor) (Insuraner. Company/Pobq- N-dmbzr) (Expiraoa Date) (?`tame of Contractor) (Insurance Company/Pohcy Numbs) (Ex-pinion Darr) (aaAich-'6Ir';0czl 6-cct if note-ury to¢emu&utfocmaaoo peruiains w.11 oocr =o: I am a sole proprietor and bave no one working for me. ( ) I am..a home owner performing ail the work myself. NOTE:pl=s be& -arc d",It_Jc bom crAmcsY[rbo employ p,-tom to mp.,ir•,•-ork a,.d..ctL_Z of not M'xt tJL•n Q'sm LMra III[[bjt Ux bon= ocr rCad=oc oo tbe QouD ap pu�tbc-,o a. oo(E--ncnDy cecrd-mi to be calploy—unec the. k=i=�-+=L%tion Aa(GLI32=1(5)),apptampoo by a bomnoa=fer:6c=r—or pazna rr-ty e•76^coot ibe Ic1PJ r=a oft=es,loyo uodar dw Workoet Coepoama.tio¢Act 1 uadast[od tb&a oopy of Uxi.mtrmca m.-y bo forwur<Sed to tbo pop—of 1nm+.uiJ Amdr=d ofGoe of Ina+r[noa for tb. ' oova->_Sc vcrLclioo and UvA Ui=c to secure`eovc-Cc undor soczioa 23 A of).tog 132 ma Icad to tbo-poiIIioc of aimi"pe—wl 000zi-i of a riot of up to S 1-500.00 anWar of up to one year end cMJ pmahio in d)c form of a$top Wort Ordr=rind. fim of S 100.00 a day ap-iast mc. For dcp.rtm=�uac Doty Pcrmlt Number Lot ; r ' 0 03ce ;.;: Versionl.7 Commercial Building Permit May 15,2000 SECTION 10 STRUCTURAL PEER REVIEYY(780 CMR 11;0 11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION 11,y,OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT,; l.P< as Owner of the subject property hereby authorize f 5 to act on We in all tters relative to ork authorized by this building permit application. Signature of Owner Date 1, ✓C' r as Owner/Authorized Agent hereby declare t 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. y . Print e ` b7 Sign u of caner/Agent Date SECTION.;12 -CONSTRUCTION SERVICES Fr 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expirati Da Signat e Telephone SECTION 13 YYORKERS'`COMPENSATION INSURANCE AFFIDAVIT(MG L c 152,§25C(6)) 3: .. e afJ', 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...... ❑ Versionl.7 Commercial Building Permit May 15,2000 'SEC,CTIflN 4 Cgi33CE1*TbF�N CLt�SEt�SPCf ; S RErS aESS f HAM S►OOt1 n m Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building [ J Repairs QC] BRIEF DESCRIPTION: . e,d' fpX 73 7 5 j A SECTION'S USEiGRoIiP ANO C()NSTRUC�IOM YPE; USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B I ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential R-1 ❑ R-2 ❑ R-3 ❑ SA ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COINPLEfE 1f .SFCT OI i "E?Q5fI1�1GG Bl 1 I 1G 111�ijEI OI IG REN0 M-,0N5,AUDI IONS.ANi�JOR'CHANGE IN llSE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): MT,FIRIP SECTION b:BUILDTNG HE3GHT:ANDAREA' BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION NLb �t Ik` Floor Area per Floor(sf) 1n 3 15[ 2"d nd 3 rd 3 b w b 3 r 4"' 3y <: � � �` k � S}✓*W�Sp 4�Y S Total Area (sf) Total Proposed New Construction (sf) � _ a Total Height(ft) Total Height ft---------- - x �s ; :. Versionl.7 Commercial Building Permit May 15,200 City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING -�SECTION l=:Stiff�N1FUtIMAT�©N 1.1 Property Address: on�olefiedfRoe , � . //� /j /� ,,�//J \/'1 "�F k7.CNI�-V©s7�� "O • A■�'/; , F'�'�ta'"eA?,�.�€a `.� ,.a' .°``' $.�`*��'���`9'i��_4�afd'�t+�ds�C�. 's�"' �.,4.: T. `SECTION'2 ,'�PROPERTYOWNERS1iIP]AUTHORIZED:AGENT ` 2.1 Owner of Record: Nam (Pri ) urrent Mailing Address: sf c�' i o o to 2 i 7 9-3 ;L- Signature C eY 2.2 Authorized Agent: X_ /4 tcti Name nt) Cu Mailing Addr 66,y -- Signature Telephone .SECTION 3 ESTIMATED°+CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be -Official JJ se Ohky completed by ermit applicant 1. Building g Permit Fee` 2. Electrical Esdrated Total Cost of �.�,�� rastrucbon°from:6;° ` 3. Plumbing Buldmgerm�t fee k 4. Mechanical (HVAC) 5. Fire Protection 6. Tota1 = (1 +2+ 3+4+ 5) v ,JCtaedc=Number Tfs:SeCton.Fcirt)tficial.°Use-On1 Bu�ld�ng'�Perm►t:Nur�ber � _ .._ P - Date Issued ` Signature: Building`Gommissionee/Inspector of Buildings Date O���MPTO ti$ Lrif r of Xarf4ailtptan Z = � � j�rlassacl�icseffs V5" , DEPARTMENT OF BUILDDhG INSPECTIONS / INSPECTOR 212 Main Street • Municipal Building North,-unpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as Lis/her construction sups: sor. T he state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fancily 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 any 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 process requires 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 permits in conjunction to the building permit issued, and that 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 I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations d 600 Washington Street Boston,MA 02111 =v°y° www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address:_ �i City/State/Zip: I�le,�►cr �t oi. Phone.#: 1//J S Fy-13,:D Are you an employer?Check the appropriate box: Type of project(required): 1.E-1 I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. r_1 New construction 2.[�I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp.insurance.$ 9. Building addition required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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.❑ 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. xContractors 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. lam an employer that is providing workers'compensation insurance for my employees. 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. 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 certi and the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: L11V0 Phone#: / �s Li _ . Z O Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑r` Name of License Holder: t�y� � /l° �✓ S 17 9 7 License Number Addres Expiration Date Signature Telephone 9 Reaistere�Home lmpraemeritContra`ctor: .' s Not Applicable ❑ J!Y jr o Company Name Registration Number Address V Expiratio ate Telephone yr 7J SECTION 10-WORKERS'COMPENSATION INSURANCE,AFFIDAVIL(M.G.L.c.1:52,§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...... ❑ Y r 5477= s I .. Homes©Winer,, 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 buildine 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 SECTIONS-DESCRIPTION OF PROPOSED WORK(check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other IR Brief Description of Proposed // / ire, / Work: CI&I-f 47e1/J& '} Alteration of existing bedroom Yes _No Adding new bedroom Yes X No ✓ Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll 42- house.AR" addffl a Rfiid nou`sina,•cOmnieW!&' f owIna: a. Use of building:One Family�4 Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached?_ P1-)_ d. Proposed Square footage of new construction. 37 S Dimensions S S 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 L 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 AG'ENT.OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 as Owner of the subject property hereby authorized G �� to act on my behalf,in all matters rp6tive to work authorized by this building permit application. Signature of Owner Date 1 % ,as Owner/Authorized Agent hereby declare t t the statements an information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under th pains d penalties of perjury. Print Name 1 V7 / Signature of Owner/Agen ate 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 Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Verianne/Fnd ing ever been issued for/on the site? NO 0 DON7KNOVV YES 0 IF YES, datoissued: IF YES: Was the permit recorded at the Registry ofDeeds? NO C } DONT KNOW YES IF YES: enter Book ' Page and/or Document#' � �� �� B. Does the site contain o brook, body of water orwetlands? NO ��. DON7KNDVV �_� YES ��/ IF YES, has u permit been or need cu be obtained from the Conservation Commission? Needs tobembtaioed 8btained ��` Date«.� �~� ' . C. Dn any signs exist on the property? YES 0 NO ' |F 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 oris it part nfo common plan that will disturb over 1acre? YES ���) NO K~��� |F YES,then o Northampton Storm Water Management,Permit from the DPW iorequired. Department use on yq \ Eity of Northampton Stags a r>t Building Department tb Cuter etuaeg 21'2 Main Street Serer a atlabtlt ` Ig Room 100 Wteel> btitty �` > - 3 ''37 Norttlampton, MA 01060 _ phone 413-587=1240 Fax 413-587-1272 FtotStt Plafts � r APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ` 1.1 Property Address: This sect1on'to be completed by office s Lot Snit Zone OVeday Distract V1 Ce E m st.C19seact cs;nl�t dt SECTION 2—PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: ^ ✓ll Cel-'c."C4. -r 14114 2eJ1�Gp� 41 cC/�°�l,. (� , j�J DLE�clo �J or Name(Print) Curr Mailing Address: Signature Telephone S b 2.2 Authorized Agent: Name rint) Current ailing Addre . , Signatifre T 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) O. Check Number This Section For Official Use Only Building ermit Number. Date 9 Issued: Signature: Building Commissioner/Inspector of Buildings Date r-40--v File#BP-2007-0926 APPLICANT/CONTACT PERSON DOUGLAS ANDREWS ADDRESS/PHONE 89 LONGVIEW DR FLORENCE (413)584-1370 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 oaf I 1P Typeof Construction: FINISH BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 078947 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFg MATION PRESENTED: L., 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 (4�Ld 7 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. liWt &DR BP-2007-0926 GIs#: COMMONWEALTH OF MASSACHUSETTS 200_ A 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-2007-0926 Project# JS-2007-001511 Est. Cost: $6500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DOUGLAS ANDREWS 078947 . Lot Size(sq. ft.): 10541.52 Owner: MCCREARY HEATHER S& Zoning URA Applicant: DOUGLAS ANDREWS AT. 66 BROOKWOOD DR Applicant Address: Phone: Insurance: 89 LONGVIEW DR (413) 584-1370 FLORENCEMA01062 ISSUED ON:411012007 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT 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 4/10/2007 0:00:00 $50.00327 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo