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'ON IVSOdO2ld uoijona;suoO 1aO lVS0d0Xd D FS tom-' T C � t� rn �� � ➢ � O 0 D > s • p TZ rR -n T_ rp i L rr O D r rn C / flr c Cl. yc r— y T L � � a� � 7 - r C °rlr F- p Z S L O L Z p� m lP c A s ii) 73 7 D 73 D 7u 7u y r- m ' Dc � O v rp -ate N a c o yl�0 D 73 j f I1 �3 > D T c rp 79 C ? 3 ! f TZ S, n r- O D Q L rn o 0 r c P i L 4> O Dt C7 J D Gl 776 f Q rS rT, m d Tm- '- � L C7 • Ul 1 'r A r-- V� f � t T �J 1 V G Z" 6' d ti Z i n 7? �1 J -1! 7 0 D! - - ---------------- r> ro a � r T N c 30 F `� n, T a v1 J y1 t- U 1 57 n 1 � 04010 Vw'NO1dWVH1aDN �, r" ti SNORONSNI JNIali(19 30 1d34 ¢.�IiAMP�O Crx� if 'Nort4ttlllpton B �liS4$Cl(nSrttS s m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (1lcensee/permlttee) with a principal place of business/residence at: IST, 0 ► C � (phone#) (str=t/city/sta&Zip) do hereby certify, under the pains and penalties of perjury, that: I am an employer providing the following worker's compensation coverage for my loyees worlang on this job: a rt�uianceiCompany) (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/Poticy Numbcr) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attadt additioml sled ifneoessary to include information pertaining to all ooatractors) ( ) 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 homeowners who employ person:to do maiatcaancq a> O°or mpen`vow to be; of not mote than throe units m which the homeowner resides or oa the grounds appurteusat thereto are not geoull]y employers under the worke`s comperis4ca Ad(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal stabs of an employer under the Workeet Compensation Ad. I understand that a copy ofthis statement may be forwarded to the Departmced oflodwixiel Accida Offiw of a--ca for the coverage verification and that failure to sw=ooverago under section 25A of MGL 152 can iced to the imposition of criminal penalties oonsisting of a fine of up to S1,300.00 addict imprisoamait of tip to one year and civil pc:,altia in the form of ft Stop Work order and a firm o(5100.00 a day agaitsst tie. For dpp-t�—only Permit Number Wp#____---Lot# Si of Licensee/P ttee 2 , SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: g:y �kA. License Number Address Expiration Date JA Signature,e Telephone Not Applicable ❑ Company Name Registration Number 15% ND Address Expiration Date Telephone SECTI©Ni 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 affidavit 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)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 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(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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature bl New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ 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 V No Plans Attached Roll ❑ - Sheet w : h 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?, NO d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating?. C—v% C&-�s 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 Y No 1 j. Depth of basement or cellar floor below finished grade it k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SCT1ON:7a-,OWNER AUTHORIZATION -TO BE COMPLETED WHEN OSNNER&'AGENT,OR CONTRACTOR APPLIES FOR BUILDING 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 eclab that the stat ments a d 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. Pri Na e LP Signat caner/Age 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 Building Departme�nt—rte Lot Size ( 1 C) o ~' Frontage Setbacks Front 3 c Side L:� R:�_ L: 'jam t R: I o" Rear i LA Building Height Bldg. Square Footage a 0 i ` I Open Space Footage �c�j© % (Lot area minus bldg&paved /(� �/l'1_� ('�I� '70 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 No IF YES, describe size, type and location: i of Northampton r u ing Department 2 Main Street l4 Room 100 rtha pton, MA 01060 DE?t Of BULL I -587 1240 Fax 413-587.1272 NC~R?HAM APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE,INFORMATION 1.1 Property Address: d This s � ` +3 het 3 > ILI y SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: I Na a(Print) Current Mailing Address: n }y--s— at re Telephone--j 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 Onl Building Permit Number! 0 161 Date Issued: Signature: Building Commissioner/inspector of 8ulidings Date File#BP-2001-1014 APPLICANT/CONTACT PERSON CDT CONSTRUCTION ADDRESSIPHONE 158 NORTH MAPLE ST (413)585-8677 PROPERTY LOCATION 1152 BURTS PIT RD MAP 35 PARCEL 198 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid c T eof Construction: CONSTRUCT 21 X 6 ADDITION TO ENLARGE BEDROOM/BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 003666 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: _Approved as presented/based on information presented. r/Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed �mding Required under: §�3 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 Comm Sion Permit from CB Architecture Committee 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. File#BP-2001-1014 APPLICANT/CONTACT PERSON CDT CONSTRUCTION ADDRESS/PHONE 158 NORTH MAPLE ST (413)585-8677 PROPERTY LOCATION 1152 BURTS PIT RD MAP 35 PARCEL 198 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 `v LTeof Construction: CONSTRUCT 21 X 6 ADDITION TO ENLARGE BEDROOM/BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 003666 3 sets of Plans/Plot Plan THE LLOWING 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 Co ission Permit from CB Architecture Committee —)_Co/.7-40N Signature of Building OfficiaF 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. f BP-2001-1014 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: ADDITION BUILDING PERMIT Permit# BP-2001-1014 Proiect# JS-2001-1811 Est.Cost: $16962.00 Fee: $63.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CDT CONSTRUCTION 003666 Lot Size(sq.ft.): 11543.40 Owner: LOCOCO SAMUEL J&SANDRA E Zoning: SR Applicant: CDT CONSTRUCTION AT. 1 152 BURTS PIT RD Applicant Address: Phone: Insurance: 158 NORTH MAPLE ST (413) 585-8677 Workers Compensation FLORENCEMA01062 ISSUED ON.61281010:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT 21 X 6 ADDITION TO ENLARGE BEDROOM/BATH 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 Occu anc si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/28/010:00:00 3762 $63.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo MOM MEN VMS MOT Y0 MITI joy AW 3 Y 9 i �tv ty. 5 � t t H OEM spa 6F �ip a QM Now a F 1 4 A FIG 3` y: t ^ 3 4 q ^ t sty 1�0 LV this ON My C d" : fib 0. Room, 4 rid Y f r i p T M,- q.� f WIN yx a� "v - r_ z 2 ! Y !�. F - MW ,.. rvY6m^�„➢u- +...` ,xe^iz;3'z,kP<A:�"»n,n+•fl�:.a�+'+.�.�l s;,. �. t. l E..-.. .57,,.k3YM d<H.v 1152 BURTS PIT RD BP-2001-1014 GIS#: COMMONWEALTH OF MASSACHUSETTS Map Block:35- 198 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:ADDITION BUILDING PERMIT Permit# BP-2001-1014 Project# JS-2001-1811 Est.Cost:$16962.00 Fee: $63.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: CDT CONSTRUCTION 003666 Lot Sze(sq.ft.): 11543.40 Owner: LOCOCO SAMUEL J&SANDRA E zonink:SR Appliedw. CDT CONSTRUCTION AT. 1152 BURTS PIT RD Applicant Address: Phone: Insurance: 158 NORTH MAPLE ST (413) 585-8677 Workers Compensation FLORENCEMA01062 ISSUED ON:61281010:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 21 X 6 ADDITION TO ENLARGE BEDROOM/BATH 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: +d�/�'%� Rough:/v�/'�f y House# Foundation:©k Q Final: /� /�2�� Final: f ho 1,#A R, Rough Frame: AK C� Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: C K THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occuvancy si nature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 6/28/010:00:00 3762 $63.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo