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DEPARTMENT OF BUILDDT G INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WOM ='S COMPENSATTON INSURANCE AFIFMAM
with a principal place of business/residence at:
, 11 oi �62-
(streeUci ty/stafe/n P)
do hereby certify, under the pains and penalties of perjury, 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)
(circle one) and have hired
the contractors listed below who have the folio er's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
If
(Name of Contractor) (Laurance Company/Policy Number) (Ex#ration Date)
(Name of Contractor) (Insurance Company/PoLicy Numb(-,r) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Ex;)ration Date)
(atla.c}r additional rlictt ifnoc�ary to include infocmatioo pertniaing to all cxe7 rs)
( ) I am a sole proprietor and have no one working for me.
am a home owner performing all the work myself.
NOTE:please be aware that t�bilc homco"ixra who crnploy paiom to do mainlcninc, d o0 or repair uoric ou a dwelling of
not rno"than thrco units in which the honvoctvcr raider or oa the grounds appurtenant thado arc ocl grnCf-211y oocJidcrcd to be
employcrs under the wo la's ccanper=tioa Act(GL152,sa 1(5)�application by a homcoavcr fora liccnsc cc Pcrmd may evidcnoc the
leg,1 etatua of an omploya undrrtho W"kees Compomation ACL
I undcrstwd that a oopy of this ctatcmmt may bo forwarded to the Dgwt,,c of Industrial Accid-&Offioo of(nauxnoo for the
coverage vrrif catioo and that failure to acatre covcnLv under sectioa 25A of MOL 152 can lead to the imposition of criminal Penalties
oomisting of a fine of up to S 1,500.00 and/or imprisonment of up to one year and civil pm,,Ni in dx form of a Stop Work Ord--and a
film of 6100.00 a grtinst me
FOf dcp t Numl es only
�.�.— Permit NtrmbeT
wpa l Lot#
Si lure of Liccnserrpermittee e
.0 -- -
SECTION,$ =CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e e .i "m me n pr 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 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)familie
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(
you hire to perform work for you under permit.
The undersigned"homeowner"certi s nd assumes respo ibility for compliance with the State Building Code, City of
Northampton Ordinances, State and cal Zoning Laws a State of ssa setts General Laws Annotated.
Homeowner Signature
€.A33 N3 M Rd' � I» QM�B�k.Sk �' Y 3 V Ii�
SECTIONS-D SCR R 1I0. 1IfOF PROPOSED WOR 3 check all a livable z
a t nza"�% Ya : wrn 7 33 r A
,New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
ccessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
ief Description of Proposed Work: b, ( Ith sew 'f-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement ✓ Yes No
Plans Attached Roll ❑- Sheet❑
6a:It Ne n ho Ikea tl or addJtJ6AA6 e, tft1W '6_ s'ini73. complete hesfoltow n :
a. Use of building : One Family Two Family Other y
b. Number of rooms in each family unit: Number of Bathrooms ,2 Z
c. Is there a garage attached? QS
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? C/ =
f. Method of heating? 614- 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
�
j. Depth of basement or cellar floor below finished grade f
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 -GENT OR,CONTRACTOR APPLIES FOR BUILDING'PERMIT
)<Lk1A'J as Owner of the subject proper
hereby au rize v��- I< to act
my beha in all matters tive wor uthorized by this building permit application.
I
Sig r of Owner ate
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
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
ft 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
rFi1j1.:. e&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:
r
Q EC E Q VE I of Northampton
ding Department
JUL L 2 6 2QQ� 12 Main Street e 7'
Room 100
ort ampton, MA 01060 s .
DEPT OF BUILDING eror4l3-5 7-1240 Fax 413.587-1272 'F'lat/Sete
NORTHAM?TON,MA 01060 t7t erpe
NOW'f. `,..n...
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE'INFORMATION
This section Lobe completed by office
1.1 Property Address: AA g �e
Rz
W d6
M.aP 'Lota� � �Unat
�
zone OverlayDist
Elm.St. District CB Distr"ict
SECTION;2 - PRO'PERTYI OWNERSHIP/AUTHORIZED AGENT
.1 Owner of Record:
CQ 1c,,, �r
Name(Print) Current Mailing Address: �J r p
Telephone O
Si ature
2 2 Authorized Agent:
eat I� . �i��n,n 1� (�ox��c.�•� �r.
Name(Print) Current Mailing Address:
-S-�Y3163
Signature Telephone
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 �O (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit fee
4. Mechanical (HVAC)
5. Fire Protection q _
6. Total = (1 + 2 + 3 + 4 + 5) 900 Check Number 0
T 's Section Fo VP fficial Use Only
Building Permit Number: ate Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0103
APPLICANT/CONTACT PERSON KUHN SCOTT
ADDRESS/PHONE 17 WOODLAND DR (413)584-3163 Q
PROPERTY LOCATION 17 WOODLAND DR
MAP 35 PARCEL 300 001 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
Tvpeof Construction: CONSTRUCT DIVIDING WALLS IN BASEMENT
New Construction
Non Structural interior renovations
_ Addition to Existina
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
INFO,HMATION 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
7-27.41
Signature of Bolding Of&kol 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.
•
7,WOODLAi`TD DR BP-2002-0103
GIS#: COMMONWEALTH OF MASSACHUSETTS
flock'3s' 306 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0103
Project# JS-2002-0147
Est.Cost: $900.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 40205.88 Owner. KUHN SCOTT
Zoning: SR Applicant. K U H N SCOTT
AT. 17 WOODLAND DR
Applicant Address: Phone: Insurance:
17 WOODLAND DR (413) 584-3163 O
FLORENCEMA01062 ISSUED ON.7/27/010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT DIVIDING WALLS IN BASEMENT
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 7/27/010:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo