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DEPT Of BUILDING INSP IONS o
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A I '' AVIT
UV!/Y/`f I"r, (00 Ls CW�-
(IicenserJpermittee)
with a principal place of business/residence at:
(?0 mtltw_ .Sr 144 YAgo*,,q yl,-t-;f PU (phone#) 363a�
( city/state/rip)
do hereby certify, under the pains and penalties of perjury, that:
I am an employer providing the following workers compensation coverage for my
mployees working on this job:
r—ftl'f►srl— 6 6piffRAL, (W6->(?MiVC W VX- D(ad4aH173 oo 3 6 71
(I>LStrrance Company) (Policy N (Expiration Date)
( ) I am a sole proprietor, general contractor o homeowner ( le one) and have hired
the contractors listed below who have the following compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
If
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Fxpiradon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml s}xet ifneccsssry to include infocmaaoa pertaining to ail eoaftnctors)
( ) 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 whilo hoaycowcxrs who employ persam to do c=1trtiction or repair work on a dwdliag of
not more than three units is which the honmwner resides oc oa the ground:anurtcunnl thacto are no(gercraily ooasidcred to be
employes under the woricces ocaipcsnatica Act(GL152,ss 1(5)),application by a homcow ncr for a liccrsse cc permit may evidcaoc the
legal status of an employer under the Workceg Compematioa AoL
I understand that a copy of this rwconcut may bo forwnrd,ad to the Dcpnrt,,o of 1a&t ,l Aocidc&Offioe of Invurenco for the
coverage vcrifica ioa and that failure to aecttre covcrago under sxtioa 25A of MGL 152 can lead to tho imposition of criminal penalties
com rmg of a fine of up to S1,500.00 andlot imprisoamest of tip to one year and civil pcn216 es in the form of a Stop Work OcdG and a
fuwak 100.00 a day tgainst m
Foe dgxrtnrot-1—O4ly
t permit Number
----Lot#
4 µ Y gnahrre of Licensee/permittee e
SECTION 8-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : W044s. f. 01 9 d N P P114- d 0 -)- /7'a O
License Number
I D C.oruyo Y( L' S6��L lG G- S 0 I0 fs 2L V/0/2.0V 1—
Address Expiration on Date
o y13 -- I�i 3
Si nature Telephone
pP
Not Applicable ❑
(-L.CI�(rtNG 6� ^SV✓/t'{M/NL� I' Lf. /eJG..�(�H�f! f- CJ�NN/f��
Company Name Registration Number
1%, 4-1" s� �Q 3g`7 100%
Address Expiration Date
..-Telephone 0�-
SECTION 10 'W02}�ERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25;C(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
orthampton Ordinances, State and Local Zonin Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
SECTION S DESCRIPTION OF PROPOSED'WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other'K
Brief Description of Proposed Work: ��2W�40 zota4i—XW Apir-K
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6 Ifi Newhouseantl
��� `�"` or�addition=to'existirig hotiS'm� :complete='the=°following:
a. Use of building : One Family Two Family Other 01 X y 0 r 1 n p ,^O(4 nao
,oQ3O !
b. Number of rooms in each family unit: Number of Bathrooms 1
c. Is there a garage attached? }4 e °�<( , v ^h
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 X_K 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
SECT lO 7a, OWNER AUTHORIZATION 'TO BE'COMPLETED';WHIEN
OjNNRSC�EIT ORONTRACTOR APPbIES FOR:BUILDIrIG PERMIT
�.:
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.
Z P Name
Signature Aof 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
Frontage /C 5�
Setbacks Front
Side L: R: L:4-&—R:_11_9 /
Rear w
Building Height O
Bldg. Square Footage /R'�1 % 0
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
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:
4
4?, ,.r,� �, _ fray
�,__, � � r.,' R:, _ ._
�..
i
DE C E 6 V E oloom Northampton S tuso�Perm�tk
g Department Guri �u IDr"ve
JUL 3 0 2001 Main Street s weds p r a�tae
100 Wa e:We11 ova
No[tharipton, MA 01060 Tw 5etsof t G a
DEPT OF 8UILQ*fflpEAdQm587 1240 Fax 413-587-1272 i?otlStefPlaPS °
NORTHAMPTON,MA 01060 X33 `
Ot erSpec�f�r
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office'
1.1 Property Address: l ,
tPa Maptot lk a knit
done r � OvertayD�str��t
„ElmsSt''District' CB District � --
�_ ..
SE ICTION!2 - PROPERTY OWNERS HIP/AUTHO,RIZED AGENT
2.1 Owner of Record: r(�
C aV,/ r\c �rS' o �pP 0/�6a
�2 �ds�� La ������
Name(Prin Current Mailing Address:
S8 7— 97
Telephone
Signatu
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIQN 3 -.ESTIMATED CONSTRUCTION COSTS f
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 =0 + 2 + 3 + 4 + 5) Check Number a---
This Section For Official Use Only
Buildi,ngPermit Number: Date Issued:
Ssignatura
r Daate .
A�, , Burt, ►rig Comrrtlss1oher/�'hspectot of Bui,Idtngs , .
File#BP-2002-0111
APPLICANT/CONTACT PERSON ANDERSON CLARICE JEAN
ADDRESS/PHONE 62 LADYSLIPPER LANE (413)587-9242 Q
PROPERTY LOCATION 62 LADYSLIPPER LANE
MAP 35 PARCEL 228 001 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
Typeof Construction: CONSTRUCT 20 X 40 INGROUND POOL
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
INF9RMATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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
Signature of Buildin fficial 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.
2 t"V V* BP-2002-01 11
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Inground Pool BUILDING PERMIT
Permit# BP-2002-01 11
Project# JS-2002-0158
Est.Cost: $9000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 32452.20 Owner: ANDERSON CLARICE JEAN
Zoning: SR Applicant. ANDERSON CLARICE JEAN
AT. 62 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
62 LADYSLIPPER LANE (413) 587-9242 O
FLORENCEMA01062 ISSUED ON.8131010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 40 INGROUND POOL
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 8/3/010:00:00 522 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo