29-224 42
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMTENSATTON INSURANCE AFFIDAVIT
(litxnserJpermittee}
with a principal place of business/residence at:
(phone#)
(strcet/city/state/aP)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Inszrrance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiratioa Date)
�f
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insumace Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach a6ditioc2l sb5tci ifnecc=xry to include infarmxtioa pertaining to ell ooatm on)
( ) I am a sole proprietor and have no one working for me.
46-1 am a home owner performing all the work myself.
NOTE:please be aware that while hoarnwo=who employ pazom to do maillj�omstr=oc ar repair work on a dwelling of
not macro than three units in which the hornoowncr re3ide3 or oa the gnuncls appurtenant thacto art not gcneralty ooandaed to be
employers under the worker's oompcusatioa Act(GLI52,m 1(5)),application by a homoowncr for a Uccwc or permit may evidence the
legal status of an employer under the Workces Compenxiion Act-
I undastaad that a copy of this ctatcmcat may ba forwarded to the Dcpert.m of Dial Aoci&.&Orhoe of Iuwrsooa for the
coverage verification and that failure to sxure coverage under sociion 25A of MGL 152 can lead to the imposition of aimi W pcaali:cs
comistiug of a fine of up to S1,500.00 alwor imr It of up to one year and civil penalties in the form of ft Stop Work Or&r and a
fin*of 5100.00 a day agniast.,lne.
l
For d }y
r
epsrtlsxnsal �trso
permit Number
-Z�' d� wo Lot#
Si of Ltcensee/permittee Date
r
77,77 77-71
SECT ON 8-CONSfiRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
me n r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
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, Ste and kocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature_ Z-�, W
s
'S�CT'OfV Q�S YP O`Id` PROP�Oeir --mu -K1LChgcKJ al a licable
.i V3H�'X #Wf H17 fi T 33bY Hk '3i VE NRA]/y ,+ b'Q_ 3 � S„.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:I&PlArl 9�'�'e�(� W l 4s, 1��iJ1�RJgG 1J/
Alteration of existing bedroom Yes t/ No Adding new bedroom Yes ^ No
Attached Narrative 0 Renovating unfinished basement —Yes No
Plans Attached Roll ❑- Sheet 0
6 Ifi a o e a id o dclit� n"to ezisting;liousing,xcom01 he`#6111 o i R:
a. Use of building : One Family X 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? k C2d Fireplaces or Woodstoves ✓ Number of each
g. Energy Conservation Compliancew Mascheck Energy Compliance form attached?
In. Type of construction IL06d / 41C
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 j(j�
k. Will building conform to the Building and Zoning regulations? (z Yes No .
I. Septic Tank City Sewer Private well City water Supply _
SECTION 7a OWN ERAUTHORIZATION' TO BE COMPLETED WHEN
OWNR5 AGENT O;R CONTRACT.OR APPLIES`FOR,BUILDING PERMIT
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
G r
v . i 2 a wne /Authorized Agent
hereby de are'that statements and information on the foregoing application are true and accura e, to the best of my
knowledge and belief.
Si d under the pains and penalties of perjury.
EnecAty J �JV►-eN JR
r t e
f Z l ZvuZ
Signa re of 0 4/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
Lot Size SF �
Frontage
Setbacks Front (q '
Side L:3_R: 9,9 L: R:
Rear —. G +
Building Height 26 ,
Bldg. Square Footage 1240 Hs:. % I OZ l-
2G2'5h, Z 57h o�
Open Space Footage I1342- �3 %
(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 /1
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 X-
IF,YES, describe size, type and location:
4W. ..,
7 '--�ity of Northampton
C0
I I }E3uilding Department r �
:,i i; , 212 Main Street a
Room 100
-�lothampton, MA 01060s
l phoneJ413 587.1240 Fax 413-587.1272 to
�flT Ci P V�
_ 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 o#ftce
He ` 7
Map LotUntt
Zone ? `— T O�ertay bisfrict b
�Elm St.`District CI3 Distrkt
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�' Y'/
Name int) Current Mailing Addres p
r ,l w Z _ l J 173
Telephone
Sign—atuAr-
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS'
Item�A /` Estimated Cost(Dollars) to be Official Use Only
/(/l G✓ 1 IJ6 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) TDO
co
Check Number
This Section For Official Use Only
Building Permit Number: b 3 " d Date Issued:
Signature:
' Building Commissioner/Inspector of Buildings Date
File#BP-2003-0420
APPLICANT/CONTACT PERSON O'BRIEN ROGER S JR
ADDRESS/PHONE 136 ACREBROOK DR (413)584-8473 Q
PROPERTY LOCATION 136 ACREBROOK DR
MAP 29 PARCEL 224 001 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 V30
Typeof Construction: REPLACE PICTURE WINDOW WITH BAY WINDOW
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,F14ATION 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 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.
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136 ACREBROOK DR BP-2003-0420
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 29-224 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category BUILDING PERMIT
Permit# BP-2003.0420
Project# JS-2003-0716
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 14897.52 Owner: O'BRIEN ROGER S JR
Zoning: URA Applicant: O'B R I E N ROGER S J R
AT. 136 ACREBROOK DR
Applicant Address: Phone: Insurance:
136 ACREBROOK DR (413) 584-8473 (�
FLORENCEMA01062 ISSUED ON:10125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PICTU RE WI NDOW WITH BAY
WINDOW
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service��/ (TIi/ i Meter:_
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:v,,
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0 K l I ,q �3
THIS PERMIT MAY BE REVOKED BY THE C Y OF NORTHAMPTON UPON VIOLA N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/25/02 0:00:00 3130 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo