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m DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A ' { AAVIT
(licensec/permittee}
with a principal place of business/residence at:
(phone f)
(street/city/stale/zip)
do hereby certify, under the pains and penalties of penury, that.
( ) I am an employer providing the following workers compensation cove uge for my
employees working on this job:
(Insurauc: Company) (Policy Number) --- (Expiration Daze)
1 3IIl a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
0 i-f3 0
(Name of Contractor) (I_usuranee Company/Poky Number) (E.cpiration Date)
(Name of Contractor) gnstlrance Compaffy/Policy Number) (Expiration Date)
(Nance of Contractor) (Insur-anc-- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Rolicy Number) (Expimtion Date)
(attach additional s ct Fncc—ly to include information pataiaing to all tnL:acton)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcssc be aware that w;tifc hoaroAn ra who cr:play pczzoas to cio ma rare,.cr cc r r lu o w wng of
not more than thrb units in«Bich the homeowner residca or on tho grounx aPNdcnant tbcnte arc not Ccncrzlly 0nsidcrcd to be
cmploycrs undo the-or{ i cernpc;ration Act(GL152,=1(5)),application by n homeowner for a license cc permit may cvidcace the
legal etzbu of an employee under the Workces Compomat Act
I uodcntand that a copy o£thia ctatcmcat may bo fot—ntdad to the Dcpartn tit of Indiutrial Accidmt>'Ofrioo of Iua,rwce for the
coverage vaif cation And that failttre to Secure oovcrago undkr scciioa 25A of MGL 152 can lead to tha imposition of--M'l lxaa cs
oomiuting of a fore of up to S1,500.00 and/or imprisonment of up to one year and civil penances in d)C forth of a Stop Work Order and a
fino of 5100.00 a day against ar-
1 �
t For only
' permit Numbc T
Lot#
Si ttrc of Li crmittee
SECTLON''8 =CONSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : I��iH�►1 '7j�icNw717{� d5-3 7Z-Y
License Number
tik
/— /d--01/
Address` Expiration Date
o' t 3S°`3/
Signature !` elephone
� Re" " dHo" e to r
�en a w � Not Applicable ❑
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► �t5
Company Name Registration Number
3U Q t AV— s�a� � � nr rm�w�0 Qr106 -n 3
Address Expiration Date
Telephone - . S
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...... ❑
11 = Homer"OW er�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 strictures 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 4 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
r e..•ir, 9s,C>»> yki„Vi+,Sa.. y r ., .,. s,.S s£,k,::,ix..> _ ..
New House ❑ Addition ❑ Replacement Windows Alteration(s)V#-_,,, Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other[ ]
Brief Description of Proposed Work: ,Va vAry
i
Alteration of existing bedroom Yes eA ,No Adding new bedroom Yes —No
Attached Narrative ❑ Renovating unfinished basement Yes _moo
Plans Attached Roll ❑ - Sheet❑
6a If NeWJ1rdUse�a�rrdAdf0d dition.to"existing housing,�1`td 0lete' the�folfowln :
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 corstruction. 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 ater Supply _
SECTION 7a,-OWNER.AUTHORIZATION -TO BE COMPLETED WHEN
OWNERIS,AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _ Z V O C)'/ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that th6 statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Sign der the pains and penalties of perjur .
r
Print fy�me
IgnapiZe of ner/Age*- Date
• 9
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
Fill:
volume&Location
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 1ere any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
i
f Northampton t ...
hl;lding Department
I fir '212 Main Street
i m„
MAY - ? r�.n� Room 100
"�� NortKi npton, MA 01060
_,phone 413:587$1240 Fax 413-587-1272 htOtllte 1 ' r
I •` Other��pac�f,� �s�'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to 6e completed b�office
1.1 Property Address: F � �
nv
gl
/,�/�'j�,�.��•� /,/{ ap f - Lot � �� A" t ,;
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File#BP-2002-0951
APPLICANT/CONTACT PERSON Brian Greenwood
ADDRESS/PHONE 366 East St (413)527-3531
PROPERTY LOCATION 41 ALAMO CT
MAP 29 PARCEL 130 001 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 7
Typeof Construction: REMODEL BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License 053724
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Co sion
.mac r
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.
41 ALAMO CT BP-2002-0951
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 130 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit BP-2002-0951
Project# JS-2002-1543
Est. Cost: $7900.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Brian Greenwood 053724
Lot Size(sq. ft.): 12283.92 Owner: SMOLENSKI JOHN A&ELLA L
Zoning:URA Applicant: Brian Greenwood
AT: 41 ALAM0 CT
Applicant Address: Phone: Insurance:
366 East St (413) 527-3531
EASTHAMPTONMA01027 ISSUED ON:5113102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATHROOM
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:% 1 , , Rou :�,. House# Foundation:
g J g . '' S
Driveway Final:
X �
Final:��?� Final: (,��� U _
Rough Frame: O
j.
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: (� -1;2.eg
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATON OF
ANY OF ITS RULES AND REGULATIONS. ,r °'' �' , j' 40,
Certificate of Occu anc Si nature:
Fee Type: Receipt No: ate Paid: Check No: Amount:
Building 5/13/02 0:00:00 1675 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo