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29-203
OTC I W f nT0 Gc%i Ica y :, R : E Crri� of partilt-1111P foil " � � e �7c�snchncrlta DEPARTNIE14T OP DUIL0r)\'G INSPECft01.'S _ 212 TIain Street ' Municipal DmIding Northampton, Mass. 01060 WORIC R'S CONQ'ENSAUON INSURANCE A ` AVIT -7' +t,-k oV-YR_CN (li ccusaJperml ttlx) x,.rith a principal place of business/residence at: C ba— FL,0 0 hone.'} (strct/ti ty/staicla P) do hereby certify, under the pan' sand penalties of perjury, :hat ( ) I am an employer providing the following, worker's cotnocnsaDon Coverage for Iny emplovecs wor�ang on this job: (Lnsmancc Comr,y) (Polio; Nu-mlrr) ----- (T=:-pinion Dais) ( ) I am a sole proprietor, general contractor or homeow-Der (citcie one) and !lave hired the contractors listed below who have the following worker's coonen a6on policies: (Name of Co=cto-) (InR!ranc; ColnpanyfPouc; Mumbo-) (_\)11-dt:oi Date) - (Name of Contractor) -- (Uisurancc Company/Poky `unccr) (Bpirttion Date) (Name of Connector) Gnsufanc: Compan)•/Policy Nzimb�.f) (Expirdoa Date) (Name of Contractor) (Ittntran Compzay/Policy Numb r) (L-xpiration Date), (aazdt ad'?i;;ocal c'xct if ucc—ry tD inctudc informa-600 pertainins to aL occr—C_on) O I am a sole proprietor and have no one worLing for me. ( } I am.a home owner performing all the work myself. NOTE:ply be awl tt e HU, 0 1b��oa��,��o�u�—,��,wbo cmplQy p,<=w&= .-•.-,.te a r�x �rcpau wo k oa a d..clln�of ao.(most ttLa t4 _L-aro to wtx,C]Lt,,l)()[I?J(J�l)CS rcvdo CK CO Lhc QOUp Z77ltr�tbcaD,oo( oc-crd--rd to be employes unlc ttxµa kriz oa _tioo Act(GL152.n 1(5)),appliotioa by a hom row=far:be n-a perma=y c ld�cx the legal clams of en—ployx under dro Work,ola Coav-c lion Aa- 1 uo'Q—d d-a oopy of ttui marctocnl may be foc^,nrrle•d to the Dopartmcol of Ic>dti[ricl A—&=&OT,—of for tbo oovm-6t vc i'cslioo&M ttu Utmc to soauc covcTt,&�m,�icr soetioa 25 A of N(01-152 an load to the LmposiGoa of almiail pca+ttia 000sutmg of►fine of up to S 1-500.00 and/ex ilr�ri of up to one year eod aviJ pCm1Uo in Cx focm of o Stop Work Order rind a fim of S 100.00 a day against me For dcqutrnr.�l u,c only permit Numbcr Sl�aturt: of Li 'cnniucc —D�e r ISTRI.I TION.;S ftC S 6.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone EE " Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTIQN ? WpRKERS C�MPENSI#T ON INSURANCE AFFIDAVIT{M.G L c:152, 2k* 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...... ❑ 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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 1p N 1i c is New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ 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 No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 s CTf©N 7a-t WNER AUTHORI ATIUN� TO BE COMPLETED WHEN 1NNE S AGI NT K t D ITE ACTt}R AP"�LIE 1�'OR UILCII G RERM17 k)C,_V (C 4 as Owner of the subject property hereby authorize J _-P&T1ZU U'K x I y 125� to act on my behalf in all matters relative to work authorized by this building permit application. Q'h fA - I "_4LA,_ g -7 Signatu wner I 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. Print Name Date Signature of Owner/Agent 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 X 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: P City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413.587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SEC?IQN'1-SITE INF'QRMATION 1.1 Property Address: 3` SECTION'.Z PROPERTY OWNERSHIP/AUTHORIZED AGENT", 2.1 Owner of Record: Tl �f"6y 121CH I 36 6 47T C NamelPrint) _ Current MajLLog Address, Telephone n ure 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone ' SECTION 3 ESTIMATED CONSTRUCTION COSTS, Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit J'ee 2. Electrical (b) Estimated Total Costlof' Constructio0:f M 3. Plumbing Buiidin Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 + 3 +4+ 5) Check Number This' ecltinn'Ftir official llse,:Onl Building Permit Nurrmbert- . Date Issued. Sigrtaturee .,13ulldirsgC6�lnmissia�ter!!r►sptc�rdf E3uirl�ings ' pets r 35 BEATTIE DR BP-2001-0134 GIs#: COMMONWEALTH OF MASSACHUSETTS a :Block:29-203 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofin g BUILDING PERMIT Permit# BP-2001-0134 Project# JS-2001-0205 Est.Cost: $2500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot Sizes .ft. : 1001 8.80 Owner: RICHI TIERNEY E Zoning Applicant: RICHI TIERNEY E AT: 35 BEATTIE DR Applicant Address: Phone: Insurance: 35 BEATTIE DRIVE (413) 584-6634 (� FLORENCEMA01062 ISSUED ON.•817100 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Jnderground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 Shmature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/7/00 0:00:00 6256 $25.00 ro, 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo