35-109 r '
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JvvRVCJ;,r,HIVU !J NVI 1V v� vvwJtRVCU AJ AN ACCURATE
SURVEY AND IS NOT TO BE RECORDED.
NOTE: THE PREMISES IS LOCATED WITHIN FLOOD ZONE C,
WHICH IS NOT CONSIDERED A FLOOD PRONE AREA
ccS.oJ '1
41 i
TO : BANCBOSTON MORTGAGE CORP. &
FIDELITY NATIONAL TITLE INSURANCE COMPANY
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL 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 #
�Q���-/��� �' J--�'� -NOTE-
SURVEYOR:
THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
-MORTGAGE LOAN INSPECTION PLAT-
&'r RMUJkLL NORTHAMPTON, MASSACHUSETTS
C3 tZEE! PREPARED FOR
;35032 ROSEMARY M. SKIBA
FSS'��o�` SCALE: I "=30 ' MARCH 8 , 1994
Dtu HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
:d 235 RUSSELL STREET - HADLEY - MASSACHUSETTS
��1LAMPpO
��'° afl Crz#� iaf fax#f�ttnt�r�ult _ -
c
�aSEFCI(ttEf IIE
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORK-ER'S COMPENSATION INSURANCE AFMAVIT
(licenseeJpermitiee)
with a principal place of business/residence at:
Li v 4A ' hOlff)l' t '67L>i
(st�rci/ci ty/statrizi p)
do hereby certify, under the pains and penalties of perJury, that
( ) I am an employer providing the following v orker's compensation coverage for my
employees working on this job:
aasu.=ce 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 foli_o�11111ng worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Numbcr) (Expiration Date)
t.
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance CompanydPoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E,�T, iration Date)
(attach additional slxet ifnoccni y to inchsdc infonnsli on pertaining to all ooatradon)
O I am a sole proprietor and have no one �' orldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homcowvm who crnplay pcjo to do r•u3fc�corrstr=oe or repair work oa a dwelling of
not more than throe units in which the homto"mcr r=dca of m the V DLL x apNrtenarl lhacto arc oot gully ooasidatd to be
cmploycn under the wvrk .o=pcsatioa Aix(GL152,=1(5)),application by a homeowner for a uc=30 cc permit may cvidcacc the
Iegal antra of an amployof uoderthe Workcez Compomalion AcL
I undast=d that a copy of this etatemmt may be forvearded to tho Depertmco2 of Indaatrial A=&-&Ofhoo of Insurance for the
coverx venfieation and that failure to accrue coverage under section 25A of MGL 152 can lead to the imposition of criminal peaaltics
oomisiiag of a fine of up to S1,500.00 tncVor imp-sonmrnt of up to one year and civil pm lti a in the form of a Stop Work Ord--and a
firm of 5100.00 a day against tnc
Fo�Nliml:
only
P
` Lot 4
Signature of Ltccnseclpermittee e'� •_
WO
S�CTJON,gCONSTRUCTI,ON SERVICES
8.3. Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : I , r L�M t •�
License Number
Address Expiration Date
JI,.--__
— C-
S nature %- Telephone
mprvementCo tractor �`, ' NotApplicable ❑
Pp
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 afflc
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act
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
i .
SECTION"D'ESCRPTI�OFIPROPOSED�IIIOR che�ak«a11 a licable �°
3 ...n m'T...Rue'5.,�x.✓'�J3YS4x-�,,, ....'s f4%&-m9'b sy„xa„�'-r. <t n +,r.2*s 3 3w._IWd k�1,�A 3313f1 M1 Y n: t4RH �41 D.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ C // _Q Ne ns
Brief Description of Proposed Work ( te<L-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll 0- Sheet❑
6a ,1VN' in%hoia" e d f klitlony�to"�EZis11ng�Fiousin :cori plete�the.foll.owinir:
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,,7�,,,�,OWNER AUTHORIZATION-.T09,EIE COMPLETED WHEN
OWNERS., f CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject prope,
hereby authorize ]�<N 1 � 0 i'r ti, h L�'` to a
my behalf, in all matters relative to work autl�o'ized by this buil ing permit application.
Signature of Owner Date
r
L;14 , as Owner/Authorized Agent
hereby declare tha a the s ern a 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.
r
i
e '
PAM Name
Signature of Owner/Age t / Date
i r T
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/Findin ver 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:
of Northampton
(c; �' `a Iding Department
12 Main Street SS
Room 100
F E 3 2 ? 2002 mpton, MA 01060 eF _
phone 4 3-5 7.1240 Fax 413-587.1272 PotW�Slte
„ �rycarCfIONS d lae`rSpbc �-.
GiN.,
CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be com e by4office
ted
1.1 Property Address:
1 97
h.
Lot' Onrt
Ma P � .�
jp-
Al tk ~�-�--- ��v__P�rta; DtstrIcty
Zone
ELI
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: _
J Telephone
Signature
2.2 Authorized Agent: _
Na e(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