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35-185 (9) �7 � Qk . to 2 Mƒ m � ; k � &" > 0 ■ § § ° % § � Ek � ' 0 2 22 a � Wk § � - � • � � k q � G - § » E • J R Cl) CYN CD 0 / § Oo R. g 0 pit m R & CL rQ N 0 k Ak. � x ■ § / f § I § K � . . 0 0 r: ..• 0 rA m ID �`�1 �j N p N�'q O !•+ O h� cr, $° Cr LkF J ' O O n4 0 N N A e F.t. to b eo cr Im O A RD O �° a cr o °- a a a m N O" Fo O tD O tz rO F� a O ►e O ,a,, ,?,d. t:e;..rrz�n..rvrsavrr'fiS (rp, ,/frr-rf.dixrs<l: Hoard of BoUdia=RsZaktiiom aad tipsmkrds HOME UU UMNEW CO*TR4CTOR Royiat=0-: 111932 EXPInUfott: 02MOD03 Typo: DBA DALE'S STEAK S CARPEM DALE HAMEY PO BOX 273)8 LW PER RUSSELL HUNTINGTON.MA,4100 Ad�iai.trator �1 mm"I ,{tlNt2�ilI"s *X~.MAVAM Tr no logo ReshieWd To, 00 TM+UK Alm, ,.. ... ` 4-�t�PTO �0 a � 6 �lasaachnsctta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORICER'S COMPENSATION INSURANCE AFFMAVIT (licensed ttec} with a principal place of businesslresidence at: U rJ (phone#) L((-3 (street city/ tip) do hereby certify, under the pains and penalties of pegury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance 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 following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) ,. (Name of Contractor) (Insurance Company/Policy Number) (E)cpiration Date) (Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sheet ifnxesasry to include infornlafioa pertaining to ell eoatradors) 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 ernploy paiom to do r 3 ,�consuuaion or rrpair work on a dwelling of not more than throe units is which the homoowncr residcs of oa the grounds appurtenant thcr o arc not gc owilly co=dc cd to be employers under the wvrl�s compensation Act(GL152,ss 1(5)),application by a homcowna for a Haase of perma may cvidcaoc the legal ctatua of an emPloyec under the Workeet Compa=atioa Act I understand that a copy of this rut=wat m.y be forwarded to the Depwtnro2 of Indushid Ac6dw&Oftioo of Insursnco for ttm coverage vaificatioa and that aadure to&==coverage trader section 25A of MGL 152 can lead to the ikon of aiminal pcaalt- oomisti ng of a fine of UP to S1,300-00 WWOC imprison of UP to one year and civil Pemlties in the form of a Stop Work OrdG and a fmo of SI00.00 a clay against me. For dgwtwr use only Permit Number 1&0 Lot# _ ;y Signature of LicensedPermittee MEe om)1a� raga n y i 1 I 3, SETbNC0IS7RUCTION SERVICI_S 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: N`e �•�\E'�! d 5 License Number Address 10 SO Expiration Date Signature Telephone Not Applicable ❑ Corn, any Name T Registration Number 8 L) �e j- Q�USSe �� r © a- -07 - loo 3 Address Expiration Date - O 1075-0 Telephone AIR SECTION 10 W, IKERS'r 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 affida 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 Officials 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 pen-nit. 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 M E EC�lON D SC PTION�OF�PROPOSED �R ch ck al) a tlCaD1'4 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other Brief Description of Proposed Work: T— S, Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes _No Plans Attached Roll ❑ - Sheet �If Neanr house and or �tld'tian excsti "MINK a. omp'le a he fotlowir : 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 f 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 STE,COMPLETED WHEN O�IYNES AGENT RCO ONTRACT4R APt?�1E FORUILD GPERM17 , /7'1 w' 'f as Owner of the subject propert hereby authorize a D&Z f '' C �� t y to act my behalf, in all matters relative to work authorized by this buil ng permit application. o7 Signature of Owner Date as Owne thorized A hereby that the statemen s and informa on on the foregoing application are true and accurate, to the bes o my knowledge and belief. Signed under the pains and penalties of perjury. � e Print Name Signature of Own r/Agent 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: 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 I 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. Ar there any proposed changes to or additions of signs intended for the property?YES IN IF YES, describe size, type and location: orthampton QE C E p v lui Department lain Street m 100 a JUN 2 9 2CALrt on, MA 01060 e. o a phone 413-5$7-1 40 Fax 413-587-1272 Pa �S�te:P DEPT Of BUILDING INSPECTIONS Qt erSpe , , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1,- SITE INFORMATION This section to be completed by1office EA 1.1 Property Address: a p p rQ Map ''Lot3 � Llnl# _, Zone, strrct � Urn St. District` CB4District SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT_ 2.1 Owner of Record: Name(Print) Current Mail' Address: Telephone Signature _ — O 2.2 Authorized Agent: e t i !� �� l Name(Print) Current Mailing Address: 3 — (PW — 31 t�c>k Signature Telephone SECTION.3''- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building 3 (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: 6l 1 Date Issued: Signature: Building Commissioner/Inspector of Buildings', Date