29-169 (3) �11ANP 0
9 � �lila aCh RSC11a
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton., Mass. 01060 '
WORKER'S COMPENSATIO I INSURANCE A F'MA.VIT
(licenserJpermittec) ----
with a principal place of business/residence at:
8C Mf} (phone#)
(street/city/staLelzip) Z3��?r�
do hereby certify, under the pains and penalties of perJury, that.
N-1 am an employer providing the following workers compensation coverage for my
employees woring on this job.
(Ins>Lrana� Company) (Polio Number) (EAimtAn Date)
O I aril a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors fisted below who have the fb2owing workers compensation policies:
(Name of Contractor) (Insurance Cornpany/Policy Number) (Expiration Datc)
(Name of Contractor) (Lnsurance Compaiiy/Pohcy Number) (Expiranon Date)
(Name of Contractor} (lnsumact- Compacy/i'eticy Nuulber) (Expiration Date)
(Name of Contractor) (1-L,mance Compan}'/Policy NumL��-1 (Expiration Date)
c,,";.ch additional race!ifnecesssry to ine}ucle informsfion pertaining;n el]ooa`rac'.on)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while h0mcowlxr3 who czaploy per�oai to&tr-aC=�oa,uaioo or repair work on a dwelling of
not than throo units in whx the hoQSCOwner rrsida a oa the Rourrrls apptutcnarfl thtr t atc o X gmcmlly coaridatd to be
employ—uncirr the-Grk&s ccaTcnsztioa Act(GL152-,;s 1(5)),application by a homoowncr fora license or p-nait may evidmoc the
legal ctauu of an amployer under the woriccet compmvt. Ac4
I undcruand th:t x copy of this rtatcmccd nviy bo forwarded to the Dcpnrtmcai of Indr iel Arrid:o&Offioo of Iawrsnoo for the
covcsage vailic3ti0n and tbst failme to sauro covcrago un&::r soctioa 25A of MGL 152 can Icad to tbo imposition of criminal penalties
ooasiziiag of a fine of up to S 1,500.00 and/or imprisonnxru of up to one year and civil penalties is the form of a Stop Work Order and a
fins 01 5100.00 a day igainsl UN
For deputlnc: l use oaty
permit Number
�� Map;t Lot# _
Sigaa of License ermittce e/
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction,,Supervisor- - Not Applicable/❑y
Name of License Holder:S�CA2) CF]/"�rt�'�lt� CSla%!?`I 1
Q License Number ?
Ad ss Expiration Date
Signature Telephone
!fie t
ed li. m r. vemen .ac r ,„� „� �� �1 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone 7 S70
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...... ❑
'Aq
11. . HoineUneEempt1°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 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 o;i 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
SECTION'5=i011E 1 TIbf�OP PROPOSED WORKS check all a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: k6Nn Wm"a Q Fr6k SrJZTP 4 PaL
hem, S l&6 i Rc�o(_ ctXw'E' . G Pa-+v ilxTCw�tn� j U 7t►??�E>
Alteration of existing bedroom Yes_V__ No Adding new bedroom Yes _ No 1`240w4
Attached Narrative 0 Renovating unfinished basement Yes JC No
Plans Attached Roll ❑- Sheet❑
6 � W ote V Ra I'VIN U' ad - e :
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
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 AG ENT,O,R CONTRACTOR APPLIES FOR BUILDING PERMIT
5T& K&P-) G2 7- as Owner of the subject property
hereby authorize ��IJ�P' -� ��� 7U ___ to act on
behalf, in all mat rs relativ to ;fork authorized by this building permit application.
1C'
Signature of Wer 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.
AQ /
Print Name
cd
Signature of er/A nt Dafe
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 there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
y of Northampton 5fatusatF'er .'r ''+
(- h� (ding Department Curb Cu vewa er ��
1 OvL ' 3 CJ01- 12 Main Street 5�ewefl,Sptic a�t� t s Jd ' M
Room 100 Wat r�V+efA_ lab ,
of MA A� ,. '
�111DiNr,tNs C1iomt4orth mpton, Two Sets ofd r ctur>a Plans
-1240 Fax 413-587-1272 Plot/Site Plans
Other Specl �� �
' S,
. yxa
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
Map Lot Unit
t--Z0'LCjvc%&'- MA- Zone Overlay.',District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT — — --
2.1 Owner of Record:
Name(Print) Current Ma Iing Address:
Telephone
Signature
2.2 Authorized Agent:
l p�Gc�r 'gti ZZ o;*S xmi• _ O X ? �2c:mf-D_Gt.J _
Nam Print) Current Mailing Address: 1 nag
33 6 ---- --
Sign. ure 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) � 'Q� Check Number
This Section For Official Use Only
Building Permit Number: _ Date Issued: - _
Signature:'
Building Commissioner/inspector of Buildings Date
File#BP-2003-0018
APPLICANT/CONTACT PERSON PROSPECT BUILDERS INC
ADDRESS/PHONE P O BOX 302 (800)486-4976
PROPERTY LOCATION 80 DEERFIELD DR
MAP 29 PARCEL 169 001 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
Typeof Construction: REPAIR DAMAGED RAFTER ROOF SHINGLES REPAIR SHEETROCK FROM TREE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 017699
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN�]�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 ssion
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.
•mow/
r •� BP-2003-0018
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0018
Project# JS-2003-0030
Est. Cost:$8000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PROSPECT BUILDERS INC 017699
Lot Size(sq. ft.): 32931.36 Owner: BRACKETT STEPHEN J&KAREN A
Zoning:URA Applicant: PROSPECT BUILDERS INC
AT. 80 DEERFIELD DR
Applicant Address: Phone: Insurance:
P O BOX 302 (800) 486-4976 Workers
Compensation
EAST LONG MEADOWMA01028 ISSUED ON.718102 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR DAMAGED RAFTER, ROOF SHINGLES,
REPAIR SHEETROCK FROM TREE
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 7/8/02 0:00:00 17444 �60
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo