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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AVTT
I, -
(li�nser'Jpernittee)
With a principal place of businesshesidence at:
(phone#)
(streei/city/stafelrip)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job-.
(Insi=cc Compauy) (Policy Number) - (Expiration Date)
O I a-n 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 Compauy/Poficy Number) (Expiration Date)
+r
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Nasie of Contractor) (Insurance, Compaay1Pohc-y Number) (E.�Tiration Date)
(Name of Contactor) (Insurance Company/Pohcy Number) (Expiration Date)
(attach addit onsl v1—if n—ry to i"xludc infortnstion pertaining to all coc�actofs)
O I gun it sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:plisse tx a rue that ti lc homcnuixza who«uploy pazoas to So ma nfcnincc =,&rucioa or repair cork on a d"'Iting of
not tneee thin throw units in wtveh the ho•—ver residcj or oo the grojrds appurtenant thercio a.'t not gaXrally ca-.sidcrcd to be
employers under the wocktes axt :satin Act(GL152-"1(5)),application try a homco%vna for a license or permit may cvidcnoc the
legal rtatua of en oarployor under the woukcls compauatioa AcL
I undtr:tarrd thst a copy of this etatemcat may be foswardad to tho Deportma,2 of rndLa1tS 1d]Ac66c 1&Offioo of lr xrrsnco for thn
co-mge verification and that failurt to scout cove-v under section 25A of MGL 152 can lead to tho imposition of a miatl pmdt'es
ooru hang of a fine of up to S 1,500.00 andrer imgzisoauxzrt of up to orx year and civil pcaaltia in the form of a Stop work Order and a
fsna of S 100.00 a day tgnit&me--
For only
Permit Number
r� 'Sigua of Liccnscc/Pcrmitfce e
SECTI ON'S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
r rm . " _. v Not Applicable ❑w } mn . " t
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1.,I dome :� ne ge. pw is n.
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.
omeowner Signature —
SECTION 5. DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ DemolitionIX New Signs ] Decks
` \ [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: neurw;����a�
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes �✓ No
Attached Narrative 0 Renovating unfinished basement Yes ✓ No
Plans Attached Roll ❑ Sheet❑
6a."'If NeWJ house-andsor:ad"dition to:existin tiou"sing;Complete=the follovrin
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 _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
SECTION 7a-OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS 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
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
Signat re of Owner/Agent 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 Department
Lot Size -3t o? fcr4i
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 t✓ 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:
i
f
D. Are there any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
-iEy-� Northampton S a
1g1212 Main Department Curb lq
212 Main Streete
MAY 1 5 '�n(�,, RQom 100 Wae
`v(�7orthamoton, MA 01060 T a.5
phone 413-587 l 40 Fax 413.587.1272 PioSiteP. '
'--APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sector to becomplete lyof�fce
1
p►nQ �Ol,��e-f V�tY�d MaPt o
crr'Px1c� N1c1 C'710(oaCoO � ZoneOrverlayDistr t
Elm St. District CB District'"
SECTION 2 -PROPERTY OWNERS HI AGENT
2.1 Owner of Record:
m"Q + Am C`.�L Us 34/ Pt►v Val" tad 4 010(A a
Name(Print) Current M iling Addr ss:
4 �� s`bto -aoti g
Telephone
Signatur
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com feted by ermit applicant -
1. Building caoo. v®o (a) Building Permit Fee
f 3. -� i5. .
2. Electrical j (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
I
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0991
APPLICANT/CONTACT PERSON CHILDS RONALD L&CYNTHIA M
ADDRESS/PHONE 34 PINE VALLEY RD (413)586-2048 Q
PROPERTY LOCATION 34 PINE VALLEY RD
MAP 35 PARCEL 185 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_ypeof Construction•_CONSTRUCT 6 1/2 X 14 1/2 ADDITION FOR DINING ROOM
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
INFORMATION 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 Commission
Z O6
Signature of Building Offic 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.
�. ' BP-2002-0991
GIs#: COMMONWEALTH OF MASSACHUSETTS
,p
CITY OF NORTHAMPTON
Lot: -001
Permit: B u i l d i n g
Category: BUILDING PERMIT
Permit# BP-2002-0991
Project# JS-2002-1605
Est. Cost: $14000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 134600.40 Owner: CHILDS RONALD L&CYNTHIA M
zoning: SR Applicant: CHILDS RONALD L & CYNTHIA M
AT. 34 PINE VALLEY RD
Applicant Address: Phone: Insurance:
34 PINE VALLEY RD (413) 586-2048 0
FLORENCEMA01062 ISSUED ON.5 115102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 6 1/2 X 14 1/2 ADDITION FOR
DINING ROOM
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:
Driveway Final:
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 5/15/02 0:00:00 753 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo