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m DEPARTMENT OF' BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(liceusce/permittee)
with a principal place of business/residence at:
(phone-#)
(strCedcity/sta&2iP)
do hereby certify, under the pains and penalizes of penury, that:
( ) T am an employer providing`the following worker's compensation coverage for my
employees working on this job:
1
(Insurance Company) , (Policy Number) (Expiration Date)
E t6
O I am a sole proprietor, generl contractor or homeowner(circle one) and have hired
the contractors listed below who/havejthe following worker's compensation policies:
(Name of Contractor) (Insuran Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance ltompanyRolicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
3
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(atiadt additioail rluct ifnececziry to inc]ude infocma2ioa pertaining to all ooatrndors)
O I am a sole proprietor and have no one worming for me.
I am a home owner performing all the work myself.
NOTE:please be aware thai while hemcowncn who ctzploy'pertom to do nt = .nn wmirucuon cr repair work on a dwelling of
not nice"than threo units in which the homooavct sides or oa the grounds appurtenant thereto arc not&,M=fly eowidacd to be
employers under the worlut's oampc nsatica Act(GL152,s 1(5)),application by a homeowner for a liccwc cc P-md may-id—the
legzi aRb"of an ourployer under tho Workoet Compomation Ace.
I uadetsiund&id a copy of thu ctatcmcat may bo forwarded to the Dcpoetmco2 of Indus!:ial Accidcn&OfSoo of InvinLom for the
coverage va ificatioa and that failure to sxure coverngo under uctioa 25A of MGL 152 an Icad to tho imposition of cziminal P—Wcs
oomistiag of a fine of up to S1,300.00 andror imprisoffixss of ty3 to ow year and civil pcmttia in the form of a stop Wort:Order and a
find of s 100.00 a day against cnc_
i > For doputn't-W—only
permit Number
f
�y
bpd{ Lot#
Signahrre of Liccnsee/pe' tree -- Laze' F
0
EC IF� �r ("CON RYICI~S�'--e,'�3
R V Mal. _
8.1 Licensed Construction Supervisor: Not Applicable ❑
r
Name of License Holder
License Number
Address Expiration Date
fx
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone-
SECTION 10 ; YORKERS'.C,OMPENSATION INSURANCE AFFIDAVIT(M.G1.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...... ❑
�f
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 1083.5.1.
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 AVjJ-A�1
u.
,t f 93199} M3 I� 6 e�i
Y r
SECT ON UK KAQV05 I I ajica
Wi13e
A1`:..,`'.1,.3-
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks} Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes 'pf No
Attached Narrative❑ Renovating unfinished basement Yes f No
Plans Attached Roll ❑- Sheet❑
i n N -VINE o �11 hl lt I
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? r
f. Method of heating? 'l; ', r' Fireplaces or Woodstoves Number of each
Energy P ? ��,t
g. Energy Conservation Compliance. �' �,< Mascheck Compliance form attached. ._/'�
In. 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 AWNER AUTHORIZATION TO 13E COMPLETED' WHEN
QWNEI2S,AGENT OR:CONTRACTOR;APPLIES l OR=BUILDII�G PERMIT
l
as Owner of the subject property
hereby authorit to act on
my behalf, in 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 t e foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
WtN e of Owner/Agen 4a2_te4V_
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 3 0
Side L: R: L R:
Rear
Building Height
Bldg.Square Footage 9/ �j % /19 gig
Open Space Footage /YY %
(Lot area minus bldg&paved , C
parking) r
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/variance/Finding ever been issued for/on the site?
NO L` DON'T KNOW _ YES
IF YES, date issued:
IF YES: Wa the permit recorded at the Registry of Deeds?
N DON'T KNOW YES
IF YEAS: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ,f 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:_
�,� .p� _ ,�, _ -......a. ._.
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D _..__...._ I orthampton
Bu I Department
JK 2 4 W ain Street
o m 100
DEPT OFBUI DIN��CCINS am on, MA 01060
NDR1HP�lI M!0A 87 1 40 Fax 413-587-1272 e
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE I.NFORMAT-ION.
his sec, ,
1.1 Property Address:
Elm St-Districts
SECTION 2- PROP ERTY,OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner.of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -,E STIMATED CONSTROCTION COSTS'.
Item Estimated Cost(Dollars)to be , Official Use'Only,
completed by ermit a licant
1. Building (a) Building Permit Fee
w.
2. Electrical (b) Estimated Total Cost of
Construction from b
3. Plumbing E Building Permit Fee
4. Mechanical (HVAC) ,
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5)
;:` Check Number V'ry
43"s Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building'Commissioner/inspector of Buildings Date.
File#BP-2003-0082
APPLICANT/CONTACT PERSON BEAULIEU SHIERI
ADDRESS/PHONE 73 BRIERWOOD DR
PROPERTY LOCATION 73 BRIERWOOD/DR
MAP 29 PARCEL 168 001 ZONE URA f 6%`'?
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
Tyueof Construction: CONSTRUCT 12 X 10 DECK
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
INFgRMATION 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
°O 2__--
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.
F
73 BRIERWOOD DR BP-2003-0082
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 168 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Deck Addition BUILDING PERMIT
Permit# BP-2003-0082
Project# JS-2003-0170
Est. Cost: $500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 13242.24 Owner: BEAULIEU SHIERI
Zoning.URA Applicant: B EA U L I E U SHIER I
AT. 73 BRIERWOOD DR
Applicant Address: Phone: Insurance:
73 BRIERWOOD DR (413) 585-1636 ()
FLORENCEMA01062 ISSUED ON.7131102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 10 DECK
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:/—l�L
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: a��--
Final: Smoke: Final:(9
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. /s
Certificate of Occupancy Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/31/02 0:00:00 842 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo