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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street < Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AITTDAVIT
1 +
�� l�censeeJpermiaec)
with a principal place of busine esldence at:
qO0 n N leo/��[ FL,4,o t Ak-* 01061 (phone#)
(stree uci ty/statehi p)
do hereby certify, under the pains and penalties of pelgury, that
O I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
(� I am a sole proprietor, general contractor o homeowner circle one) and have hired
the contractors listed below who have the following Tor el's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expimtion Date)
r
(Name of Contractor) (Insurance Compauy/Poky Number) (Expiration Date)
(Name of Contractor) (Lnsw-an(v Company/Pahcy Number) (E.T rabon Date)
(Name of Contractor) (Insu=ce Company/Policy Number) (Expiration Date)
(attach amtionil r-hte ifmcc j to include infocmition pertain r.S to all«radon)
( e proprietor and have no one Forking for me.
( I am a home owner performing all the work myself.
NOTE:please be avr-Arc that vrhilo homcownc"who cm ley p ions to do t:a;atm• cr co:�oo ar repair wotic on a d"c.11ing of
not more than throe units in winch the hacrr_owrxr midcs or oa the p ou xs appurtc „d jhez o'-'not gcr t y cauidcra to be
employers under the wock&s o=rpCnsatioa Act(GL152-"1(5)),application by a homeowner for a 6ccu5e or permit may cvidcnoc tho
lesll status of an employer under the Workojc Componsation A,x.
I un&ra%zd thzt a copy of this uatcmmt may be forwarded w the Dtpartmcut of I.&LSt6d Aco&d Office of Imu+irroo for the
oovcrgg vaification and that fa nitre to secure eovcngo ut>det section 25A of MGL 152 can lud to tha imposifion of crimmai pen.+lfies
ooasisting of a fim of up to S 1,500.00 and/or i nprisonuxat of up to one year and civil penalties in dx form of a Stop Work Ord--and a .
find of S 100.00 a day a&kinst me
For dcpxtl�use only
• Permit Number
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Signature of LicroseclPermittee e
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-NOTE-
(T -[ EQSOPOM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
E rA ACCURATE SURVEY AND IS NOT TO BE RECORDED.
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ON ACCURACY IS NOT GUARANTEED
JUL 1 0 21 02
L_-L--�_,-
DEPT OF BUILDNG�A NSF CTIONS
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TO: SOURCE ONE MORTGAGE SERVICES CORPORATION &
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY # 250167
_ —NOTE—
SURVEYOR: T—• .�- THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND. DOES NOT CONSTITUTE A PROPERTY SURVEY
—MORTGAGE LOAN INSPECTION PLAT—
, T icy NORTHAMPTON, MASSACHUSETTS
RANDALL PREPARED FOR
.0 1Z. y ALBERT HERSH & SIENA AMENTA—HERSH
135032 SCALE: 1 "=30 ' AUGUST 21 , 1998
HAROLD L. EATON AND ASSOCIATES, INC.
suRV E� REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY ' MASSACHUSETTS
SECTION 8'-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
« .
4 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...... ❑
1. dome ®wnie 3em wi 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 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 —
r
'!5-DES'C'RIPTION OF PROPOSED WORK(check all applicable)
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❑
6a, Ifi�New�hoc`"1"s�"e�"ndo► aiiditlon°toxexisting�liousin�,.complete�the`.followin° :
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 AGENT OR CONTRACTOR 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
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 Na e
7 1oP
Signature o wne /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
Frontage
Setbacks Front
Side L: : R: L: R:
a�
Rear
Building Height
Bldg. Square Footage `'' %
p a--
Open Space Footage % x
(Lot area minus bldg&paved (,J
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:
A �
D thampton
III ir partment Cg r eta !D
z 21 i) Street S r
JUL 10 2002 100 w
i
Northanip o , MA 01060 T Sets o = C
L. -p. ala 24 Fax 413-587.1272 Plo 7'Stte
DEPT;OF B1,111-DING INSPECTIONS
Nnfitsa=,",l*1u, !VA 01060 e q t
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING y
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section tobtl completetl byofftceu
100 IQ�/gAl Re>A-el
�
'Lo�[.r•✓e,e Nth, OHO 6o-
Elm St. District CB District ' 3
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tb D D a . xj'Al G- YOO n ydqN ,�d. r%0&-r've e- ,At.* 0jo6,)-
Name(Print) Current Mailing Address:
IY9• --5'851 - ggF0
'49w 13, Telephone
Signature
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 // a0� Od (a) Building Permit Fee
7
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) Check Number (�
This Section For Official Use Only
Building Permit Number: � Date issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I
File#BP-2003-0040
APPLICANT/CONTACT PERSON KING TODD B&SUSAN E
ADDRESS/PHONE 900 RYAN RD (413)584-9980 Q
PROPERTY LOCATION 900 RYAN RD
MAP 35 PARCEL 070 001 ZONE SR
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: CONSTR CT 24 X 16 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
IN ORMATION 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 ion
—9Z aloc
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.
900 RYAN RD BP-2003-0040
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-070 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0040
Project# JS-2003-0112
Est. Cost: $4200.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor_
Lot Size(sg. ft.): 11979.00 Owner: KING TODD B &SUSAN E
Zoning: SR Applicant: KING TODD B & SUSAN E
Applicant Address: Phone: Insurance:
900 RYAN RD (413) 584-9250-0
FLORENCEMA01062 ISSUED ON.7115102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 24 X 16 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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:OK� 4_011
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/15/02 0:00:00 4594 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo