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DEPARTMENT OF DUILDrNC INSPECTION'S
ry-
212 1`lnin Street Municipal Building
Northampton, Mass. 01060
• woIUCTIZ'S CONTPENSAJION ENSUTzAVCE AFFIDAVIT
(1 i pus:Jperrni tttx)
,with a princip d place of businessJresidence at:
do hereby certify, under the pains 2nd penalties of perjury, :hat
( ) I am an ernptoyer providing the followine worl cr s comnensa ion coverage for Ind
employees wol�:irlg on this job
XI aJn a sole proprietor, general contractor o! hotneovw-Der cie one) �Jd have hired
tIlecone actors !;s e belo�, who hive the following wor 'e s comoens2don policies:
V;M
(NIlII1C Of Cio:) (lnsulallcc C0111pany/Pohc., Nl1SI1LYr) (l:?:):ri)UO!1 DaIC)
(Name of Coutractor) --- (Insurance. Compaml?oki , NuiDcrr) (%xpu-a Lion Date)
(Name of Conn-actor) Gn-s ranc: Comoan}•/Police NumL�--r) (Expiration Date)
(Name of Contractor) (Insuran(—_ Company/Policy Numbcr) (Expiration Date)
(auac h additioml c!xd if nccc- .to mc.lu-,3c inf m t co p�W.13
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plc--;c be aw-ac that wtnJo homcovincn who cmplay pa-,.=to do a-•rr+*m+act ooa,.ioo cr rcpav work oo•d—lling of
ON Mort than tbmo units in which the bc,=- er scmdes oe oa the pounds xppaAcawt thacco arc oo( y ooc mcla-cd to be
employm under the wor s c=pcnsciim Act(G Li5z=1(5)} applinbao by a bomcoamcr for a 60rusc or permit may cVidcmc the
` Iegal clan"of an omployor under dsn Wocic,oeg C.ompomiiioa Act
a I uadcstand that a copy of thin rui�may bo focwcrdod to tbo Dcpnrtmcaa of Indutrial Aoadrnao'Off oo of 107sr+ooa for tha
oovcngc vaiGaaim and that(_thus to ccck=oovcrngc under socuoa 25A of 1.(OL 152 can Iced to tbo imposilioa of crimi W pcmlli-
oomicting oft fine of up to S1,500.00 and/or m�nt of up to ooc year end civil pcmttia in the form of a Stop Worts Order and a
fin 0(:S 100.00 a diy egaiasl me
For dpi= uac caly
�
Pc=t Number Lot
Ma p' t rt
signahlrc 0 iccn'e permiut e
t
S'ECTION`S -CONSTRUCTION<SERVICES
1 Licensed Constructions Supervisor: / Not Applicable ❑
Name of License Holder : l �r L /A 19
License Number
Jo kl�,c�� laQ ,t�I a ins b�r�, t✓lG 67 — z zyzso
Address Expiration Date
-3i
Signature Telephone
9.Re i' �o ' .€, ..,..° f., (El� h,rt `. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone 24re=31 S 7
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.
igned Affidavit Attached Yes....... No...... ❑
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 l(/t�
r
CTION;, -- DES P O 0 QE Q b
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑ i I
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a :
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 WCONTRACTOR APPLIES''t:OR BUILDING PERMIT
I, 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
I, , 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.
ned under the pains and penalties of perjury.
Print Name /
Signature of Owner/Agent Date
r
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
n Building Department
Lot Size d6 /� o2� 76T a DJeVV
Frontage 14/7' I V I /&b
Setbacks Front %012 �a
Side L:015/ R: 37' L:on/ R: 3711*
��
Rear 2
�J C�
Building Height
Bldg. Square Footage '976074/ %
Open Space Footage % ✓
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. H cial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW
IF YES, ate issued: < y 9
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. Ar there any proposed changes to or additions of signs intended for the property ?YES
Noz
IF YES, describe size, type and location:
tfi.•+►
City of Northampton
� „ JUN ` 3 20��Build nag Department
212 ain Street
Rdom 100
ftampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
" htsf ctioin t be campyd of
1.1 Property Address:
#y
lJ� Map Lod �� f}nit,
'AP4 AYeIay Dist
1tim-St.l5istrlct C8 Df �i >wt.:'
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:5kly-
Telephone
Signature
2.2 Authorized Agent:
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 (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 +1 + 5) �7Q�, Check Number
This Section For Official Use Only
Building Permit Number: . { Date Issued:
Signature:
Building Comm iss loner/Inspector of Buildings Date
i 4
File'#BP-2000-1130
APPLICANT/CONTACT PERSON BOMBARD WILLIAM R&SANDRA J
ADDRESS/PHONE 55 BRIERWOOD DR (413)584-5803 Q
PROPERTY LOCATION 55 BRIERWOOD DR
MAP 29 PARCEL 157 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
Ineof Construction- C STRUCT(2)DECKS=312 SO FT TO ATTACHABOVE GROUND POOL
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
pproved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § —w/ZONING BOARD OF APPEALS
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
ignature of Building fficial 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.
bb
55 BRIERWOOD DR BP-2000-1130
GIS#: COMMONWEALTH OF MASSACHUSETTS
M.Block:29- 157 CITY'OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Deck Addition BUILDING PERMIT
Permit# BP-2000-1130
Project# JS-2000-2010
Est.Cost: $2700.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 20691 .00 Owner: BOMBARD WILLIAM R&SANDRA J
Zoning URA Applicant. BOMBARD WILLIAM R & SANDRA J
AT. 55 BRIERWOOD DR
Applicant Address: Phone: Insurance:
55 BRIERWOOD DR (413) 584-5803 O
FLORENCEMA01062 ISSUED ON.6115100 0:00:00
TO PERFORM THE FOLLOWING WORK.-CO NSTRU CT (2) DECKS = 312 SQ FT TO
ATTACHABOVE GROUND POOL
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 6/15/00 0:00:00 2524 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo