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35-115 � � ,,i '. (Z I! jl i , i , i ii I ' it ' I i j;l !� .:I i __ a � . 0 d y a ill i II �i y Ili I ii � I „i j I 'i ii M g t I j APR 6 ' zx i s t i I i J o\ST s (6 O,C . -1J';T f t3eAM c --s T i i i I I� �i i t . 4.�1tM1pT� O a 9 . - 8 B �+tisachnsctta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE ATTIDAVIT ��.Uj 0. w C1 C� (Ii censerJpermi tree) with a principal place of business/residence at: 727 - C- 14i,I` o✓, (phone##) `�7c�)L-1 (street city/stazP/ap) do hereby certify, under the pains and penalties of pegury, that: ( ) I am an employer providing the following workers compensation coverage for my employees worlring on this job: (lasuranee Company) (Policy Number) (Expiration Daze) ( ) 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) r. (Name of Contractor) (insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiation Date) (Name of Contractor) (Insurance Company/Policy Number) (E, Date) (atIadl adciitioail r!xe(ifncccisrry t�ix}ude infonnition pertaiuing to all o�) Q 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 awarc that wliilc homeovm=who employ pcaom to do m tuts,. cr,oaatuC oa cr repair work on a dwelling of not mode th-:n[lute units in whidi the lk-,a o vcr resides or oa the g oux ,ppurtM&,,j therdo ere no(ecrxrally oomickrcd to be eaiploys under the vwt}:a's co�ticn Ad(GL152,s 1(5)),application by n homoo Ana for a liccrise or perm t may cvidcnoc the legal ctatua of an employer undertho Wockcez Compamation AcL l undcrttwd that a copy of this Qatcmmt mwy bo forwardod to the Dcportaxvt of Indri ial Ac6&.�Offioo of L—ursuco for tin coverage va ificltion and that fad=to&cent=covcntgo under section 25A of M(1L 152 can lead to tho imposition of criminal penalties 000sistiag of n fine of up to S 1,500.00 and!«imprisoQmatt of up to one year and civil pcnaltics in the form of a Stop Work OrdG and a fum of:3 100.00 a day tgainst uy-- C For oaty permit Number c�2.. Lot Ivfap;l t m Signahue of Liccn_sc&Petmittee e SECTIO,,N,8C`OIVSTRUCTlON:5ERVICES 8.1 Licensed Construction Supexvisor. Not Applicable ❑ Name of License Holder: C ` W�` �L,,e t o'c ' License Number T� Address Expiration Date Signature Telephone Jffl�e re m 8: nr �y r ..... '. Not Applicable ❑ r'�� `�., rme Company Nne Registration Number Address Expiration hate Telephone S Z 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 affida will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... 2-' No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familic 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(. 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 � I5 k 3 v3 SECTI®N "��ESGRYPTI�NOF PROPOSE D�M1IORKcliecka'1a Iicabte , New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. )5\ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: S G �'r� � 1 ��,f ISIQC Alteration of existing bedroom Yes�_ No Adding new bedroom Yes No Attached Narrative D Renovating unfinished basement Yes No Plans Attached Roll D- Sheet IX s 1stir+g- KO—um- m corn gig- he i61,1 dwifig: 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 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 SE;CTION'7a 'OWNER AUTHORIZATION -TO;BE COMPLETED WHEN OVIINERS APP AGENT OR:CONTRACTOWLII=S rm.B.UILDING PERMIT C V as Owner of the subject proper hereby authorize l to act my behalf, in al ters ftive to word h ize y this building permit applicatio . ff IS c- Signature of caner Date % N CC 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 pa s and penal ies of perjury.. Print Name Signature of Owner/Agent Date e. ^r 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 C t%'L! , f GCS _ �i p—D—D r Frontage �(` 7t;- Setbacks Front Side L: _R: (2 L: 5� , R: Rear Building Height Bldg. Square Footage �cry -7 % i c(-& Open Space Footage (Lot area minus bldg&paved 12 CIC-10 C)��6 C C, �•`t �!/ 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 Noz IF YES, describe size, type and location: � � f IL A �R C C Northampton yi l } g Department 1 `' ri1;P Main Street e A°R 1 0 2002 ?! °' oom 100 a Nor ha pton, MA 01060 © ,t phortg 4t3 87 240 Fax 413-587-1272 ale�F'a Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section 'o-'be completed by office 1.1 Property Address: 3 per— z District t'1 AV . Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owne of Record: me VAQ CAA Name(Print) / l Current Mailingir�e p ``'�7�� 5 � w Telephone Signature 2.2 Auth ized 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 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) Check Number This Section For Official Use Only Building Permit Number: Date Issued; Signature: Building Commissioner/Inspector of Buildings Date 2002 eS � t 1 tp f`; r� 40 r File#BP-2002-0866 APPLICANT/CONTACT PERSON MCCUTCHEON PAUL C&MARCHELE ADDRESS/PHONE 77 FOREST GLEN DR (413)584-3352 Q PROPERTY LOCATION 77 FOREST GLEN DR MAP 29 PARCEL 115 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out _ Fee Paid 373T 9,3-0 T_ypeof Construction: CONSTRUCT 16 X 12 SHED 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 ATION 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 oa" Signature of Building ficial 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. 77 FOREST GLEN DR BP-2002-0866 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29- 115 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: shed BUILDING PERMIT Permit# BP-2002-0866 Proiect# JS-2002-1438 Est.Cost: $1500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq.ft.): 13982.76 Owner: MCCUTCHEON PAUL C&MARCHELE Zoning_URA :Ml%can±: MCCUTCHE7\1 PAU!.. C & MARCHELE AT. 77 FOREST GLEN DR Applicant Address: Phone: Insurance: 77 FOREST GLEN DR (413) 584-3352-0 FLORENCEMA01062 ISSUED ON:4119102 0:00:00 TO PERFORM THE FOLLO WING WORK:C O N ST R U CT 16 X 12 S H E D 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: )) 0 L- Driveway Final: , Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: "Jii I:isniation: Final: Smoke: Final:o V THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy si nature: Fee Type: Recelp No• Date Paid: Check No. .Amount: Building 4/19/02 0:00:00 5228 $50.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo