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29-265 (2) E DD JUN - 5 2001 DF RT HAMPTON,MAPO 06ONS � l 4 i t E C JUN - 5 2O1 t DEPT OFMBUILD'ONS NOR, MP1 ,MAP0�6 NS f s r 1 L f u E 60NS I L i , I a � a i f i 9 OQ�npTO •� � Crz� � ��z#l�ttnt��un $ aasxrhnsrttts' DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licenseelpermittee) with a principal place of business/residence at: oro9e, to w,tpb (phone#) a6 73 (street/city/stn Zip) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following 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 homeowner (circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional zbect if nec a nuy to include ii&rmatioa pertaining to an codraduora) 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 homeownem who employ persoat to do maadcnAncr,0=sb ioa or repair work on a dwelling of not mote than three units in which the homeowner reaid=or on the groan&appurtenant thereto arc not generally oo=dcred to be employee under the workeez ration Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidenoe the legal statue of an employer under the Worlcela Compensation Act. I underuand that a copy of this rtatcmeat may be forwarded to the Dcparmrcod of Industrial Aecidm&Of loo of Irrxuanoa for the coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the ioa of criminal penalties oomisiizrg of a lithe of up to 51500.00 artdlor imprisoamen2 of up to ono year and civil penaltiex is the form of a Stop Work Order and a firm o(5100.00 a day against t>x For uao only permit Number -lei d. Q S= O r Map# Lot 4 Signature of Licensee/permittee ..SCTI©N R=CQNSTRt1CTIQN SERVICES 8.1 Licensed Construction Supervisor: n Not Applicable ❑ Name of License Holder: O A Vi ` ✓� 05�5-90 3 License Number pd &o)( 2 90 Co"19— 02 Address Expiration Date 5� JLOIL--� _Q T 73 E9 Signature V Telephone Not Applicable ❑ Company Name Registration Number 020, Box 3 90 bu vn p ok C1169 7 —7 0 Address Expiration Date Telephone 06F' 7389 ,'CC' 0009KERS'C©MPENSATIf}N INSURANCE'AIrFIDAVIT(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....... IEY 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 4 Of P I New House ❑ Addition ❑ Replacement Windows Alteration(s) ®" Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks �,J Siding[ ] Other [ ] a Brief Description of Proposed Work:Add�CYeK ,a►o can �'�m -�c�.��y. �e.ka .�reams rGr �l-acti��••u �c„Mf 1,1 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_L,,,*' 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 5EC7fON 'a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNlER5 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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 I, t4 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. 0 rle vV1 Print Name Signature of Owner/Agent 40, Date 4 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 c/ IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property?YES No V/ IF YES, describe size, type and location: � / � �� .... t ��i c� t (�,( e�� R " !A �wu........�._,....�_,aw+.,n_ .H,....,..... ... t�" "� ., ... ti{. i V EU Northampton g Department } Main Street JUN om 100 Nor ha ton, MA 01060 DEPT OF BUvIQItY6P%1W87• 240 Fax 413.587.1272 NORTHAMPTON,MA 010W APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1;-SITE INFORMATION 1.1 Property Address: r /► grr1�lY blstrlct 9,10 t 6 strict H ;, SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 11Jnv\a id ma.✓ P�kp �o z-G" Q (_.1-ew 0✓' Flo✓Q,nr e Name(Print) Current Mailing Add ss: Telephone Signature 2.2 Authorized Agent: ))A,,,?? �vero,.. _ PO S a x 3 90 w/1,a r b u� ova 96 Name(Print) Current Mailing Address: a 3 F9 Signature Telephone =10i3=10ilt ESTIMATED CONS7aUCT10N COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cast of Construction'from' 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) (0 8' 3 Q Check Number yt 'This Se tionTor Official Use Only Building Permit Number: �` Date Issued: Signature: Building-Commissioner/Inspector of Buildings Date of a File#BP-2001-1007 APPLICANT/CONTACT PERSON David Johnson ADDRESS/PHONE P O Box 390 (413)268-7389 PROPERTY LOCATION 68 LONGVIEW DR MAP 29 PARCEL 265 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid BuildinjZ Permit Filled out Fee Paid Typeof Construction: CONSTRUCT HANDICAP ACCESS RAMP ON FRONT ENTRY REPLACE FLOOR ON DECK&REPAIR RAILS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 055903 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § —w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Commiss' Permit from CB Architecture Committee 6,6 O 2 00 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. 7 S t d � tm JIM, Y AIR to, you OAS Alaws a E to § b. N2 f y t t �` �n5 T off y W .3 ism, q1 too ." Q R , 5 �' - 4 11 1i }5 t ! h i � •:z7' i:' 'k Y 1, {' # y 11 Y -j _ .t. I I � I'll 11, ,< -, W p �d iz S X ,e ,. "' � 4 � � �� : 11 5 �p l.i � ,.t1� # ' tvtAttt4 i tCA W ID* {" ' k L■ - /[�1�� Lr' ra`fi- k"`" '� f -: m2 _ i' r - : . ` ry rl - I '.�'� - - " � , — — , I �:" I I I I -�- Ow .�:" -' I I $ tH f >li; t . I �e"'�"�:-'—'-'� �" '-- ;'-'I---`;Ci"-" ,' *+ I'll -� li"',' I , I — I w ircpseelChep: 11_ R 5 �p,, � � �� tx, : �. � � . y �.< 1 - 1 I 11 ��Y f .'{ , 1 ( _ " w /y�];i , 11 11 I - 11 i' 3 � 4 " 212"Suvet,Phone{413)587-1244,Fax:(413)58?'•1272 Building Commissioner-Anthony Patillo