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PAGE I OF
RETURN DEPOSITED ITEM NOTICE 0050264911
NOTICE DAt
�j 05-24-200:
i +
CITY OF NORTHAMPTON
C/O TREASURERS OFFICE
210 MAIN STREET, CITY HALL
NORTHAMPTON MA 01060
1 ENCLOSED ITEMS
THE FOLLOWING IS A LIST OF CHECK(S) DEPOSITED BY YOU THAT HAVE BEEN RETURNED UNPAID
TO THIS BANK FOR THE OF THAT ITEM AND AMOUNTABEING)CHARGED TO YOUR ST ALSO INDICATES THE DISPOSITION
YOUR ACCOUNT
ORIGINAL FILM
AMOUNT RET. MAKER RETURN DEPOSIT SEQUENCE DATE BANK LOCATION ID
OF CHECK RED. ACCT NO. REASON DATE NUMBER WAS CHARGED --
_ ______ _ ----------------------------
-----------------------------
- 50.00 -RET - 89420579 REF CK 05-22-2001 43532341 05-24-2001
M
ANTHONY & LAURA ANDERSEN 0089420579 1404
28 SYLVAN LANE PH.413-585-9849
NORTHAMPTON,MA 01062 10ATF
PAY TOTHE ORDER O � $
et
"'h4mQ1m,AAat-kr—tts 01027
+:0 11000 1 3 8+: ^�--
008 94 20 S ?9ii, 140 4 1'000000 5000"'
= 50.00
ITEMS
DEPOSITED ITEM(S) RETURNED ( 1) 50.00
FEES WERE ANALYZED ( 1)
LESS ITEMS REDEPOSITED ( O)
AMOUNT CHARGED TO YOUR ACCOUNT ON 05-24-2001 ( 1) 50.00
� � a
1
,
M AY 2 9 2001
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON,MA 01060
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1 AY 15 2001
DEPT OF BUILDING INSPECTIONS
kinOTNAMPTON,MA 01060
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DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Iiceusee/permittee)
with a principal place of business/residence at:
` (phone#)
(street/city/sW&zip)
do hereby certify, under the pains and penalties of penury, 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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additieml shod if necc=ry to include information pertaining to all ooatmctors)
( ) I,,am a sole proprietor and have no one working for me.
am a home owner performing all the work myself.
'C NOTE:please be aware that while homeowners who employ pc=m to do makicaaace,consbvcUon or tzpair work on a dwelling of
not morn than throe units is which th a homeowner raider of on the grounds appurtenant thateto art act generally considered to be
employers under the vmd='s cation Ad application by a homeowner fora license or permit may evidence tht
legal status of an employer under the Woelre ez Compemation AcL
I understand that a copy of this statemeat may be forwarded to tho Depvtax of Lukuttrial Ac idw&Offioe of Irrnrnace for the
00wr W verification and that failure to&==coverages under section 25A of MOL 152 can lead to the imposition of criminal peaaitiea
oousisifag of a fine of up to$1,500.00 andlor imprison of up to one year and civil penalties is the form of a Stop Work Order and a
firm of 5100.00 a day against tae
For dRUrtmeow use only
t permit Number
gyp# Lot#
of Lt ermittee � � ,
:.ya
SECTION 8.-CONSTRUCTION SERVICES
8.1 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 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 Lop Zoning Law d State of Massachusetts General Laws Annotated.
Homeowner Signature
>t
O
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks V Siding[ ] Other[ ]
Brief Description of Proposed Work: A90 1N6 `57,-4IRS 4yY.> P&O/C M R
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 °2
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 Bg COMP,L"ETI D WHEN
OWNERS AGENt OR Ct�NTRACTOR APIPLIES FOR BUILDING 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 are that t 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
u G% )
Dat
Signatur her/ gent
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
33z$7 S Building Department
Lot Size
7GY Q
Frontage
Setbacks Front -7-;' 0' 30
i
Side L: 3-�- R: L: R:
Rear 7-3
Building Height
Bldg. Square Footage �lii %
Open Space Footage % 7o
(Lot area minus bldg&paved L
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 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:
K . 7 s)
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Q E C E thampton Buil epartment
MAY 1 5 200121 n Street
00 100
DEMOOf�B��D►lvG pto , MA 01060
l 124 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION=1-°SITE'INFORMATION
1.1 Property Address: �!
yg syL v� t n0 ,�
k a
SECTION 2- PItt7PERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'07 .SQL VA A.' e-ti� /UDf�y ✓�
Nam Current Mailing Addres •
Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- F. TIAhATEf)•CB1SiSTRU0,0 GOSu
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) Gam✓ Check Number
This Section,For Official'Use:Onl
Building Permit Number: `` Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0925
APPLICANT/CONTACT PERSON ANDERSEN LAURA E
ADDRESS/PHONE 28 SYLVAN LN (413)585-9849 Q
PROPERTY LOCATION 28 SYLVAN LN
MAP 35 PARCEL 285 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
Tvpeof Construction: CON TRUCT 12 X 12 DECK&STAIRS TO A GAZEBO FROM EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building, lans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE,FOLLOWING 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 Commission Permit from CB Architecture Committee
e s /,0/
Signature of Building O cial 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.
BP-2001-0925
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Deck Addition BUILDING PERMIT
Permit# BP-2001-0925
Project# JS-2001-1668
Est.Cost: $3000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 33279.84 Owner: ANDERSEN LAURA E
Zoning: SR Applicant: ANDERSEN LAURA E
AT: 28 SYLVAN LN
Applicant Address: Phone: Insurance:
28 SYLVAN LN (413) 585-9849 O
FLORENCEMA01062 ISSUED ON:617101 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 12 DECK & STAIRS TO A
GAZEBO FROM EXISTING DECK
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 sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/7/010:00:00 1404 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo