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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORTCER'S COMPENSATION INSURANCE AFFIDAVIT
(lice>LSeelpermittee)
with a principal place of business/residence at:
(phone#)
(atr'eet/city/stafr/ap)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the follollving worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
I am a sole proprietor, general contractor or omeowner - cle one) and have hired
`contractors listed below who have the followln wor e s compensation olicies:
g P P
4 (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anaeh additional tlu<t tfnecei to incWc information pertaining to all ocatmdors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plerse be aware that v haUc homeowven who employ pc Tons to do m,�construction cr repair work on a dwelling of
not store than throe units in ufidr the homoouvcr raids or on the ground,appurtenant thm-do arc not generally comidcrcd to be
employcra undcr the workaes 00aVxasation Act(GL152,ss 1(5)�application by a homoowocr for a license oc pclm may cvidcnoc the
legal etzhur of an omployoc under tho Workcez Compomation AcL
I undentaud the a copy of this rtatcmaxt may be forwarded to tho Dcpoxwxcd of Inds xUid Ac6dcaf Offioo of luwranco for the
coverage verification and that failure to scc=coverngo under Sociioa 25A of MGL 152 can lead to tbo imposition of criminal Pen Wes
oomistiag of a fine of up to S 1,500.00 and/or imprison of tip to one year and civil pcn&Wcs in the form of a Stop Work Oslo and a
fins of s 100.00 a day agLinA mc_
` ((J /� For dcpsr W=W—only
2 "� 2 V Permit Number
YC —... �p4_---Lot# __
;.. .:
4Si1=atuZ8 Permittce, D3te
J ,
,
P
t
�SECT (?N 8 iTRUCTI0N5R%ICI:S j
.. .�:.�.3_�.. CONS t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e Hblra o ee a - n,r: r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'.C,,OMPENSATION;INSURANCE;AFFl DAVIT,(M,G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(
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 2 eta
°" i'�.
m NNW
SECTION N'DIESCRIPTION OF PROPOSED�YIIORK(cHeck�atl ap[ilicabte ���
aluxi
7„
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [.]
Brief Description of Proposed Work: L�f 1 S�Ut C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement —Yes No
Plans Attached Roll ❑- Sheet❑
f No h0 sew d o° tl iti ri to eiciskI ho° sin oai . 'le a fhe fi611
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?
h. Type of construction
K; i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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
SECTION4 7a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT,OR CONTRACTOR.APPLIESTOR OUILDING'PERMIT,
as Owner of the subject proper
hereby authorize to act
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 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.
it-h
Print Name
Ezc� f —
Signa a of wne./Agent 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
aro
Lot Size / G
Frontage 1 } 19
Setbacks Front 9 C/
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 R DON'T KNOW d/
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:
f ,
Q _ ..
rr � -
L� n , l� It orthampton t o e
T�g11 r�'Un epartment
APR — ? 2'1 ! Street s AS P r a
i "' 2 om 100 a er1We1� 3 +Y'I�'
Norfham ton, MA 01060o�SetsStr
v'` phone 4 87 240 Fax 413.587-1272 P�iot/Sete
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION,
1.1 Property Address:
Maps
1l(� Dee r et-b Dr2
Elm St. District CB Des r t
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2i.1 Owner of Record: (�
L-ollJI -s d i0 -1) (Ti LLD
Name(Print) Current MaiJin Address:
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'�Orily
com leted b ermit a licant
1. Building D� (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)
Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Sl, nature:
Date:.
Building CommissloneMns pOctor,ofS,u�3IIrl;Bs
e { '
File#BP-2002-0833
APPLICANT/CONTACT PERSON BACH LOUIS T&ELIZABETH J
ADDRESS/PHONE 110 DEERFIELD DR (413)586-7593 ()
PROPERTY LOCATION 110 DEERFIELI�DR
MAP 29 PARCEL 173 001 ZONE URA W5
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid ff77 KN�-
T_ypeof Construction:_ERECT 8 X 10 SHED
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 FOLLOWING 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 scion
y
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.
-110 DEERFIELD DR BP-2002-0833
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 173 CITY OF NORTHAMPTON
r
Lot: -001
Permit: Building
Categ-or:shed BUILDING PERMIT
Permit# BP-2002-0833
Project# JS-2002-1392
Est. Cost: $1099.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size( q. ft.): 16509.24 Owner: BACH LOUIS T&ELIZABETH J
Zoning:URA Applicant: BACH LOUIS T & ELIZABETH J
AT. 110 DEERFIELD DR
Applicant Address: Phone: Insurance:
110 DEERFIELD DR (413) 586-7593 ()
FLORENCEMA01062 ISSUED ON:418102 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 8 X 10 S ED
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/8/02 0:00:00 1577 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo