The URL can be used to link to this page

35-204 (3) C; do �a JUN 7 2000 331 35" 710 S 9G Yi-l� v 6. b a G New ShP✓� - - 0��1tM!! of �'Torilja»1pto)) _--_ g E �teseachncrlla —� o DEPARTMEN T OP DUfllJf?\,G INSf eCTIOt.'S 212 Main Street ' Municipal Building Northampton, Mass. 01060 WOMCEIZ'S COM ENSATION LNSURANCE AFFIDAVIT (ll ccuscclpcm»ttcc) \vith a piincipa-I place of business/residence at -- — - (slTr ty/state/rip) do hereby cerrifj-, under the pains aad penalties of perjury, that ( ) I am an employer providing the following worker's colnpensa.Jo cover-2^e for Inv etuplovccs wolfing on this job_ (Insttr �r Coar .) (Pelic: Nu:nir_r) :piruo, Date) ( ) I am a sole proprietor, general contractor or homeowner (cucic one) ztid hzve hired the contractors Ijsted below v,,Lo have the ',oHo\V1nQ worker's compens2tion policies: (Name of Co:t; c.orl (InR nnc Cornoan}'IPci�c, Nurn!Yr) (=>:pi;ra:oe late) (Name of COntraclor) 0SLS-'I=c;c coinpa:ly/Pollcy Nt_Mb2r) Date) (Name of Contractor) Rasurancc Compan y/Policy Numbzr) (Expimdon Date) (Namc of Conn-actor) 0-as-u c_- Compan},/Pohcy Numbs) (Exj)ilation Date) (caad�add:i:ocal c' C.d to �-_"u6:uafortn.,:ioc Penn'"'g to.11 ( ) I am a sole proprietor and have no one working for me. { Y I am a home owner perforTrung all the work myself. /NOTE:plc-_s Lc ca-Arc tLL HiJc hoarAUx z Nbo cu3q)lay pctoni w 6o r+ _=-s.. ,a r<^yau.,ora m,d..ctL.g of not tnocc tlin LL-r c t-Ir,,in uay:c+ ttx bo� &=rciido or oa the Qou z,�pv�.rtcn-r.1 theeo� r D(Ce> Ijy to be c"iploy-1 unG.. 6: cc t m Act(GLI5ZII 1(5)�_WGcxion try a botji va I'm c 1:c-�—_<a pernvt n y c.id=rx Lhc Icgal 0-:1.of e e=,lover under dw Wock-"Com .ACQ Ad. I under t. d thu a cv"of thu clztcmcm u.y bo fwc dnd to tho DcSwrtux l of ti>Ls "jrJ", &&Off o0 of It,�for tha oovmEZc vvificiion and th_t L•iltnc to ec z covcnxb-c under section 25 A of MOL 152 can la.d to the Lm,--of----I pcnellin .. oomistm of a fine of up to S 1500.00 erdrtx of up to o K year'_-.1 a'iJ pmitjo in be form of e Stop Work Ord--Dd e rim of 5100.00 e day.Fpiwl ar_ ✓/ Lot Si lun of Li _crl)'crmittcc — C ION.S-CONSTRUCTION SERVICES —.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 19-WORKERS'CCMPENSATI©N INSUIIANCE 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. ned Affidavit Attached Yes....... ❑ No...... ❑ 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 sha11 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 d Local Z ing Laws and State of Massachusetts General Laws Annotated. meowner Signature M RPM ie' New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. 'Pi 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❑ 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 Energy Conservation Compliance. Mascheck Energy Compliance form attached? 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 SE0, 10 17,a QWNIMt RUTH RIXATI0N -TO COMPLETED Elb WHEN =twVt�E AtT QR flN"ktiT(?>R "P�.11 31Fi 8�J.1LGiMVi PERMIT I. 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 I, , 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. epop*igned the pains and penalties of perjury. C,%/'l�UjGfl Pr'nt Name C*�' C '-r►. Via: ✓ C 7 Uc Sig re of Owner A t 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 7 Building Department Lot Size 3 1 3, 3 a 30✓ �� Frontage a` J , /�15_ Setbacks Front Side L: R: /D Rear 33 9 ' U Building Height J Bldg. Square Footage 1�2 69 % 175 �6 Open Space Footage % (Lot area minus bldg&paved rl -parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding Bever been issued for/on the site? NO DON'T KNOW v 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 1 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: CIty1b Northampton M80dtng Department A� 212 Main Street Room 100 Northampton, MA 01060 phone 413.587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECI II? 1 ' bT t. 11trQtMY3"ION . 1.1 Property Address: �` ,� ,� ,t � _ Z � ? y 4 T / j�� / S:ECTI4N F!ROPERTY 01�I1wtERSH1;P�AUTHO�tl2ED AGENC 2.1 Owner of Record: k-- L L P. PC's F- z <- 2 l- me(Pri t) Current iMailing Ad dreg Telephone Signa e 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone std 3 >;5T tMA*&CONSTRUCT ON QM,; Item Estimated Cost(Dollars)to be "Off ,ci af,Use Only" completed by ermit applicant 1. Building a (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) S Check Number .This Section.For Officia I Use,Onl ilding t'errriit Number o Date Issued: Slgnattare: rllttiig,Corrr�ssranerinsc#oret 8cr�lirgs . Date °" -�-- — File#BP-2000-1105 APPLICANT/CONTACT PERSON CAMPOSEO JAMES M&LORI J ADDRESS/PHONE 1268 BURTS PIT RD (413)586-1581 Q PROPERTY LOCATION 1268 BURTS PIT RD MAP 35 PARCEL 204 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid 0 o2S— Typeof Construction: CONSTRUCT 8 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: _ZZApproved 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 Commission Permit from CB Architecture Committee 6 Z000 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. 1268 BURTS PIT RD BP-2000-1105 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-204 CITY OF NORTHAMPTON Lot:-001 Permit: Building Categor : shed BUILDING PERMIT Permit# BP-2000-1105 Project# JS-2000-1972 Est.Cost: $1365.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot Size(sg.ft:): 57499.20 Owner: CAMPOSEO JAMES M&LORI J Zoning: SR Applicant.• CAMPOSEO JAMES M & LORI J AT. 1268 BURTS PIT RD Applicant Address: Phone: Insurance: 1268 BURTS PIT RD (413) 586-1581 O FLORENCEMA01062 ISSUED ON.619100 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 12 SHED 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 6/9/00 0:00:00 271 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo