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m DEPARTMENT OF BUILDIT;G INSPECTIONS
212 Main Street
Municipal Building '
Northampton, Mass. 01060 '
WORT{ER'S COMPENSATION INSURANCE Ar,MAVIT
(li cen see�permi ttec)
with a principal place of busmess/residence at:
(s ti�ei/ci ty/stale/ri p)
do hereby certify, under the pains and penalties of pequry, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance 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) (Expimtion Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Lasuranc-c Con pany/Poticy Number) (ExTp anon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atIach additional tScct if ntor_uiry to include inforrniIIon prxtainutg to all Coatre rs)
O 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 homeowncra who cmplay perjo w do mxia�coastucrioo or repair work on a dwelling of
not mode than threo units in which the hoa)6w xr residca oc ou the grcxrnds appurteneni tha to are no(&coc lly considered to be
employers unda the worker's satica Act(GL152_"1(5)),application by a homeowner fora license oc permit may cvidcnoc the
ltPl dutuo of an omployx under thn Wocico�s Compematioa Ad
I undersuad data Copy of thiX ctat=naA may bo forwarded to tho Dopwtaxod of Iod 4 d ACad�&Oflioc of Inn-far the
cova-& a vaifiication and that failure to seatre covecngo under soctioa 25A of MOL 152 can lead to the inr;xuition of airni al penalties
oousisting of a fine of up to S1.500.00 and/or of up to one year end civil pcB lti a in the form of a stop W otk Ord=and a
film of 5100.00 a day agniw l mc.
For only
permit Number
Map;t Lot#
Signature of Liccusedpermittee 1
SECTION 8,-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
F S: t
Re�istere`ii Horne Improvement Contractor ,.��a ,r��� .4_a�. � �, _ _ t „� ,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 affid&
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
. �I H wee � caner E empt o'ri
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner ae6
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 o44a,� (DLekk
SECTION 5=,DESCRIPTION O`V PR6�o!5ED WORK(check=all:apalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: hQ 1,, C>
Alteration of existing bedroom Yes No Adding new bedroom K Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet 0
6a,~"If Neini house'.and'or`addition`to ezis"ting-housin0r, completbJhe fo11d ins:
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
SECTION ,7a OWNER AUTHO,RIZATION,-TO BE COMPLETED WHEN
OWNERS=AGENTQ R CONTRACT,OR;APPLIESFOR;BUILDING PERMIT
as Owner of the subject proper
hereby authorize
__._..__..___._._._..____-__-_.� to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Da e
r 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 Name r
cu ka�
Signature of Owner/Agent Date
i
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: i�f"""►"
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:
,ls �' �� Depa e sego I ° -
lU1 l5 V l� ,
Status of Permits
Q i y of Northampton
ilding Department Curb Ctit YdDnuewayEr
12 Main Street Sewer/Septic Availabi iy s, +a�"
J U L 1 3 21201 Room 100 WaterlWell Avatlail� '
Nort ampton, MA 01060 Two Sets"of Sfructdral Plans �
DEPT OFBUIt01NG� 13.5 7-1240 Fax 413-587-1272 Plot/Site'Plans � ,q
NORru, x" ON,MA 01060
Other�Specify ��� ��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Propert Address:
��wse� I Jr Map Lot - Unit
Zone Overlay District
1o1-enc z 14 6) O6?--
T
Elm St. District CB District
SECTION 2 - PROPERTY>OWNERSHIP/AUTHORIZED>AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized AFent-
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 210 (a) Building Permit Fee
2. Electrical (b) Estimated Total'Cost of
®C) C:> Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) /
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) fl® �Q°° Check Number
This Section for Official Use Only
Building Permit Number: � J Date Issued:
Signature.
Building Commissioner/Inspector of Buildings Date'
rile#BP-2002-0051
APPLICANT/CONTACT PERSON DASTOLI ANTHONY A&ADRIENNE
ADDRESS/PHONE 12 DREWSEN DR (413)586-1604 Q
PROPERTY LOCATION 12 DREWSEN DR
MAP 35 PARCEL 114 001 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
T_vpeof Construction: REPLACE KITCHEN CABINETS&SUB FLOOR
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 C ission
/.6/.?c940J
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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BP-2002-0051
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
orations BUILDING PERMIT
1
11
PERMISSION IS HEREBY GRANTED TO
Contractor: License:
Owner: DASTOLI ANTHONY A&ADRIENNE
Applicant. DASTOLI ANTHONY A & ADRIENNE
AT. 12 DREWSEN DR
Phone: Insurance:
(413) 586-1604 (�
J62 ISSUED ON.71161010:00.00
W THE FOLLOWING WORK.-REPLACE KITCHEN CABINETS & SUB FLOOR
.RD SO IT IS VISIBLE FROM THE STREET
ping Inspector of Wiring D.P.W. Inspector of Buildings
Service: Meter:
Footings:
Rough: House# Foundation:
Final:
Rough Frame:
Fire Department Fireplace/Chimney:
Oil: Insulation:
r
Smoke: Final:
'S PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
OF ITS RULES AND REGULATIONS.
ificate of Occupancy Sip-nature:
Type: Receipt No: Date Paid: Check No: Amount:
ng 7/16/010:00:00 1281 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
r
File#BP-2002-0051
APPLICANT/CONTACT PERSON DASTOLI ANTHONY A&ADRIENNE
ADDRESS/PHONE 12 DREWSEN DR (413)586-1604 Q
PROPERTY LOCATION 12 DREWSEN DR
MAP 35 PARCEL 114 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Buildina Permit Filled out
Fee Paid
T3Teof Construction: REPLACE KITCHEN CABINETS&SUB FLOOR
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 C ission
v /,6 ZOO
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.
r
'r
F .f BP-2002-0051
GIs# COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Categorv:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0051
Proiect# JS-2002-0071
Est.Cost: $2000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 9016.92 Owner: DASTOLI ANTHONY A&ADRIENNE
Zoning: SR Applicant: DASTOLI ANTHONY A & ADRIENNE
AT. 12 DREWSEN DR
Applicant Address: Phone: Insurance:
12_DREWSEN DR (413) 586-1604
FLORENCEMA01062 ISSUED ON.•71161010:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN CABINETS & SUB FLOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/16/010:00:00 1281 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo