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'7� .. � � � \ �� � � �� � � ���1 �� .� ''.p o � � '4 � i � � i � �- I � 09 !kv � ''�,, i 1 � �--� �'"+ 1 y t 1� i v '' ,` I I y � j iI I i �` � �� ° �1 ,� i °�Kt TO ---__ F �If�l of "�Ilort1ja111ptoil - 4 6 llssxdlnsctta _— DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'a ?Northampton, Mass. 01060 WOMCER'S COMPENSA'T'ION MSURANCE AFFIDAVIT (licc�>=ttcc) with a principal place of business/residence at: A 61662— Lore0 Cps M LPwko GLLA►zf , (ph�onei,) S"k 7 — oo (7/ (str--Ucity/statrJap) do hereby certify, under the pains and penalties of perjury, that: ( ) I an an employer providing the following worker's compensation coverage for my emplovees worming on this job: (Insurance Company) (Polio Nu.-abcr) (F-x-pimtion 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 pohcies: (Name of ConL-acw,-) (Insnlranc�c Compan y/Policy Number) (Expiration Datc) (Name of Contractor) (Insurance CompanwPobcy Number). (Expiration Date) (Name of Contactor) (Inau-aac:Company/PoUcy Number) (Expimfioa Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (&Mach additiooal thccc ifnooa to mchh k mfortnsaoo pertaining to all ooa7nr_o 3) ( ) I am a sole proprietor and have no one working for me. I am a home owner performing all the work myself. NOTE:plc.sc be aware dw wfiilo boaxxwr i who employ pczon:w do m.jCjCn+ztcr,consnY,ioc or rtpaa work o0 1 d.vclling of Mot more than tbrne units in which the homoowarr rrsidn or oa the Vnunds rppurtcaini thccw apt Dot E;c3a-zly ooasidcrtd to be cmploym undo the wodccts c ompc=szlion Act(GL152-=I(5)),applica600 by a bomcowvrr far a license cc permit may cvidraoc the IcgIl ctnnso of an cnployoc uoder iho Wockola Compomaiioa AaL I undcstand that a oopy of this c. '-d may be forwwd.od to tho Dcgartmmt of Industrial Aoad=&Off oo of trau•nco for the covax&c vcrif cstioa and that L mi -w soarrc coverngc under soetioa 25A of htGL 152 can lead to Lb-imposition of erimiGA penalties cow ms ing of a ftnc of up to S 1.500.00 andlor of up to one year end civil pcathia is the form of a Slop Work Order Lod a fim o(5 100.00 1 day against mr- t' For deputm c al use only --— �/� O U Map,;t Nttmlxs Lot. mature of Lic cnscc/Pc r« . ;,SECTION 8-CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone R It Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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...... ❑ fan 0, er`�xe,"on 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 Staty and Local Zoning Laws an State of Massachusetts General Laws Annotated. Homeowner Signature •0�, . ��CTIION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ Other74 Brief Description of Proposed Work: K r°`sG 04 C j: tm X S +NCa oCieS + I NS fn LL WaGD vte Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6, If. News ,ar-'add itiarl.:t ou i ne, ComploteAhe follow r1 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 OR CONTRACTOR APPLIES FOR 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 l �L'A-'xJ(1 14 pZ4 L'PrYA 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. igned under the pains and penalties of perjury. '�(,A-N L �" Print me C Sign ure of Owner/Age 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 f 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 there any proposed changes to or additions of signs intended for the property ?YES _ No IF YES, describe size, type and location: Fia _# ity of Northampton s i,lding Departmentu bit! w r MAY 212 Main Streete , l m " Room 100 F BUi H I�NSPFtT t� th mpton, MA 01060 s� Ir?E+�T t7F 3U y . one 7-1240 Fax 413-587-1272 e� ' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address: This section to,be completed by office 40 (,V L4 Map Lot Unit 12-C tj& E � ,yam� 0 � U b ?.— Zone� � Overlay DIstriot El m St. Distct1 CB District ' SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: T4's ame(Print) Curren l� Telepl- Signature 2.2 Authorized Agent: f2('(NGIP Name ri t) CUrrE Signature Tel( SECTION S- ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building I �M �So O (a) Building Permit Fee 2. Electrical 2 S f-p V $S&-o (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 p This Section For Official°'Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2000-0988 APPLICANT/CONTACT PERSON ZEL YA BLANCA ADDRESS/PHONE 40 ALAMO CT (413)587-0074() PROPERTY LOCATION 40 ALAMO C MAP 29 PARCEL 129 ZONE URA THIS S CTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid D Typeof Construction: CONSTRUCT DECK ON EXISTING PIERS&INSTALL WOODSTOVE 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 LLOWING ACTION HAS BEE TAKEN ON THIS APPLICATION: Approved as presentedibased on infArmation presented. Denied as presented: Special Permit and/or Site I Ilan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed I 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&Reco ded at Registry of Deeds Proof Enclosed Other Permits Required: �I Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Co 'ssion Permit from CB Architecture Committee � Lead Signature of Building Offi6al Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required r ermits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. i I i k r a r f 4- ANET AQ Sony WOO 40 ALAMO CT SP-2000-0988 i GIs#: COMMONWEALTH OF MASSACHUSETTS MVv B k:29- 129 CrrY OF NoftTHAM Lot:Al Permit; 8u#Ctlrt�- ,`�_ Catcrv:vtroaove � t '�f .;PE Est.Cost yW0.00 Fe: s �SSI INIS HEREBY GRAATED TO.- cosclass. tr, star: License: Um Lot size(sa.ft): $18_ ___9Z.$_U _ . ROBINSON` ELIZAB9TH LL ' 0 UA; ` 403 ALAW '- :4413, FLORENCIEMA01062 . TQ PER FO W T "E FOLLO 40�NSTRUCT DECK ON EXISTING PIES INSTALL WO00$TOVE F©ST ff IS 4 MOM T Inspector of Plumbing Impocii rr of DWI Mw Ins or'of Bug Underground: Service, Meter: Footings: Rough: Rough: House# Fouadation: Final: Final: Rough Frame; +Gas Fir"lace/Chimney: Rougb: QI Insulation: Final: e: Final:O �+Lr "* ,�d TMS PER MT MAY BE REV BY THE CITY O OItTI MPTON. ?UFON''I IOLA:TION OF ANY OF ITS RVLES AND RRGt TIONS. !Qjrtifieft f fi . . t; cr., D eck No: Building 5/12/000:00:00 1660 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 uilding Commissioner-Anthony Patillo