35-098 (6) e 0
Crib of 'Nart4aiiiptlan z
� � �' �asartrEJttsrtts
10
DEkRTMENT OF BUILDrNG INSPECTIONS
m OF Bu "Tt6fyS 212 Main Street ' Municipal Building �I
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, ���� , I �4�✓'c mss` c_I Y'`
(licenserJpermiuee)
with a principal place of business/residence at-.
` w p w (phone#) 5%k 7 033 3
(street city/state/ap)
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) (Insura-ncc Company/Poticy Nu.mbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoEcy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach a.dditlooil sheet if necenx y to[or l lIIfOR oa pextmini o to au C ra r7)
{�() 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 homeownaa who employ Per-=to do In i.en,ann wnstnx ion or repair work on a dwelling of
not more than three units tin which the honmwna'r sidcs or on the grounds appuexnurt thereto—not Ceneraffy ooemidered to be
employers under the worker`s ration Act(GL152,m 1(5)),application by a homeowner for a license or permit may evidence the
legal ctatrrs of an employor under the Workers Compomation Act.
I underrtxad that a.copy of this sutcmeat may be forwarded to the Dcpa bar of Industrial Accidas&Offroc of Ir:suranco for the
covaxge verification and that failure to secure covcrngo under section 25A of MOL 152 can lead to the iurpositioa of criminal penalties
oomistmg of a fine of up to S1,500-00 and/or imprtsormlwt of tip to one y=and civil penalties in the form of It Stay Work Order and a
firm of 5104.00 a day against tee.
For d trso only
Permit Number --
.
7R Map# _ _-- Lot#
��: Signahtre ,iccnseeJPe 'ttee
a
, I �, •o 0
• o ,o
M
m
Z
t� > o �•
cn O
mV
Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations
NORTHAMPTON, MASS. ' (0 19
Additions
APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location " f 1�V-C1:�u bvir lr�r Lot No.
2. Owners name I Ci w re ;c....+,,-t, ivy 64r�S Address �F3 d)s--ew 5c>�v Dr.
3. Builder's name Rey ,,� y`r t fr 5'r• Address
Mass.Construction Supervisor's License No. Q ��� Expiration Date
4. Addition
5. Alteration i
6. New Porch ! ��' -J rv��caste C ��,.I S roe) �-
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cosL-K 7Y. 0c
(s� The undersigned certifies that the above statements are we to the best of his, her
knowledge and belief.
Sig azure of responsible ap icani
Remarks ��tX L�0so k (Da►C �
a Tt l 4o L s s 4 �uy,e.L< a_b O %,
tom. _ ♦ ( t
�' c..� [a�Z�� �+� � '�-[� ► v' L��.� oL X�f. �iG,'�'u`4 i-cC �.s��t.7 �3C'�1 2�7 (5 h: 3 `JQ YV9 �UJF+-C �c Ge.'� 1r' ,
..1 t c r. L 1 1.o g;r I d,,.,.� 4 �L,vr w,.Lid X",
.�--.%;0 .n r'7 c �,r✓ IvvL rv',,-�-'�
bo �. N
JUL
h I
m o Of -}-
J 1
ca
v. ,
CL
la
-rt d
' _ M
r
` T w
N _ 3-
Vl
w
\ J -L *a
-t 91-
it
At - -
DEPT flf i ` tt�J mW� O i
's- o
1
6
ki
z
ff
o f
c
s s
ro i Cll
6
J iT 8 r
0
r
9 S w
V
C � `
S
S�
10e Do any signs exist on the property? YES NO
location:and a
IF YES,describe size,type
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This col— to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size sv
Frontage
Setbacks 4/ S q M
f f
- side L: R: a 3-f L: 3 0' R:
- rear c�$� 3 6-f �U
Building height W
Bldg Square footage
0 3 bS�
%Open Space:
(Lot area minus bldg Q
&paged parkingi l
# of -Parking Spaces r
f of Loading Docks
Fill:
(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
j
DATE: (9- `� APPLICANT'S SIGNATURE
NOTE: Issuenoe of a zonin g P ermit does not relieve an a
pplioan s burden to comply witf� pll
zoning requirements and obtain all required permits from the Board of Health, Conservation
Commission, Department of Publio Works and other applicable permit granting authorities.
FILE #
A t to
Fi 1 e No
lvo�ouat. !c IHSr��lows
PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
r -- --
1. Name of Applicant: � �2 v Jd`t jr d
Address: C le 0 c-,� � � Sc►u � �- ,,,�� � Telephone: J���l 0 _3�3
2. Owner of Property: 4 vj r en,C ti I i N Ac, K a
#� �A d.
Address: Y3 0 a^e.LA-�' .S CfU Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(explain):
4. Job Location: # rV Or.
Parcel Id: Zoning Map# Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
S. Existing Use of Structure/Property s i [ry'�' Elw.JM Lo'--z
6. Description of Proposed Use/Work/Pro Cect/OCC atio : (Use additional sheets if necessary):
l�i�xt I w 0-101".A p0a, .. � eie- 4--j;:
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special Permit/Vadance/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#
9. 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:
(FORM CONTINUES ON OTHER SIDE)
" Reference No: BP-1999-0024
Department: ...................................
Building,Electrical & Mechanical Permits
.........................................................................................
Fee Type: Receipt No:
Building-Renovation REC-1999-000031
......................................................................................... ......................................
Paid By: Paid in Full On:
Robert Carrier Jr Tue Jul 07,1998
........•................................................................................ ......................................
Received By: Check No:
Linda Lapointe 1661
......................................................................................... ......................................
DEPARTMENT'S COPY Amount: $42.00
...........................
DEPARTMENT FILE COPY 83 DREWSEN DR
CITY OF NORTHAMPTON
BUILDING PERMIT
Owner's pulling their own permits or dealing with unregistered contractors for applicable work do
not have access to Guaranty Fund(MGL 142A)
Issued: Permit No: Inspector: Tracking No.: Fee:
BP-1999-0024 $42.00
GIS #: Man Block: Lot: Address: Zonin Use Group: Lot Size:
6914 35 098 001 83 DREW SEN DR SR 9016.92
Contractor: License Type: Insurance:
Robert Carrier Jr CSL
Address: License No.: Insurance No.:
16 David St 059154
City: State: Zip Code: Phone:
SOUTHAMPTON MA 01073 (413) 527-0333
Project No: Category of Work: Const. Class: Cost Estimate:
JS-1999-0037 $10,674.00
Description of Work:
construct 12'x 18' enclosed porch
GeoTMSO 1997 Des Lauriers&Associates.Inc. C.m+�t..rP•
r
File#BP-1999-0024
APPLICANT/CONTACT PERSON Robert Carrier Jr
ADDRESS/PHONE 16 David St (413)527-0333
PROPERTY LOCATION 83 DREWSEN DR
MAP 35 PARCEL 098 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 I(t, I � —
Type of Construction:
New Construction
Non Structural interior renovations '? `-
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/OcWmKt S tement or License#
3 sets o lan o Ian
THE_F,GLLOWING 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 C mmission
Signature of Building icial 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.