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OEPAR T ME1,T OP BUILD[ 1G INSPECTIONS '
212 Main Street ' Municipal Duildinf;
Northampton, Mass. 010GO
WORICE Z'S COt'IPENSAIION LTISURl+-NCE AFITTYAVIT
(ls ccUS:xJpermi flee)
ttrith a pi-Mcipal place of businesslresidence at. ?
z - dl•��'
(str�.tJci tylstalcf r�p)
do hereby ceftii);, under tic pa n-s and penalties of perjury, .lial
( ) I am all cinploycr providin- the foilov"Iml worku's comt)cns_:Don covcr2^t (or lily
eluptoyces worhng on alts job.
(Itisur-� Corp ,y) (Pelic;
( ) I am a sole proprietor, general contractor or homeowner (c cie one) a-rid hwe hired
the contractors listed below who h2ve the fOl)OwiflQ worker's c=Pen�non policies:
(Name o.Co lmct0-) (In�nnc Cornpan)vT'oue, Num�r) (->:pira:;on DaIC)
(Name of COOLTac10r) (Ossrancc ComDax,,/Police Numcsr) Date)
(Name of Coau-aclo;) (LDSUranc.-- Compan)'/POLq NUMbu) (Entnbon Date)
(N2JnC of COnlMCIGr) - (Insura� Comt:atiylPOLCy Numbs) Txp u-�itson Dais)
(ealch�6��:;oca1 c.';:c:irn«Y-v^;to cx'u�inlcxv-ia:ioc r,crti�ninr�to.11 ccc-r..c'-0:�)
( ) I am a sole proprietor and have no one Nvorldng for me
(�am a home owner performing all ti3c work myself.
NOTE:pl=x be—wu 011..: a,.Jc hccr_ I-n MtO esxPlay V—�ons w 60 :-, r `< x c re=ar"ark of
act rm c il-n QL -ua,j ui ul,•.0 a,,Ia: A-Da rrz.do a oa the p-a.wd,z,�p.utcn=m thcc.,n�--c nx ecx:lly a�c�:d�c.1 to Lr.
loy�unr',c rh_ .sicfa ca,-- _tim Act(GL152s3I(5)} -pplicaucn try e bozo o,v fct Ibis—a pcnnrt Lbc
I eg11 01.11t Of C =PIoyK acd-d).o (.O� A, C
S undc^aAnd Cbn a copy of Oaa czatc—i—y bo foci.-nr<Sod to Lb,Dns—t--x-1 of InC,,. jd ncndai OfLioo-f Ucurtoco for tha
oovcnsc ycr f�1ioo nod ttLt L J a c W sawc novel b�under soct5oa 2S A of I.(oL l S2 on Iczd to the i,oms on of civinil pcnelbcl
oomis:ivg of a rtn:of up to S 1}00.00 andtoc ca;uiwna�eri of up W one yv.r end c�til rxnit'uo�L�form of n Stop Work order end a
fim of S I WN.d--y.pima me
For dcp,nn�: a-dril y
��•�G I �''����� T a PCTM t N nII)bcl
Map;! _ Lot ~ J
Sit;nat)irc of Lim)sccf}'crniittc-
r �
-CONSTRUCTION 4, RY(CES
:1 Licensed Construction Supervisor: �1 Not Applicable ❑
Name of License Holder: '� r!'lr.Aff ' ✓mil `
License Number
� 5''� /d�9�'� •yes S ��.
Address Expiration Date
P
Signature% Telephone
.n € �r� iii» .._.. .,E.�=•
L Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
S I0 N .WBRKERS'C I IPENSAT1,001ASUR; 0E AEFIaAYI'f
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....... [5--" No...... ❑
a
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.
Homeowner Signature
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [
Brief Description of Proposed Work:
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
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?
Type of construction
i. Is construction within 1.00 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
SCION •OWNER AUTHORIZATION -TO BE COMPLETED WHEN
l IN 5wAGEI+IrT'0H�C0N 'WT OR A PLIES FOR BUILDING PERMIT
C (� r (� J /3.a. A /'t /l S 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.
-z--zr 7 / Aq
Signature Owner Date
/ L 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
%<. ,
Signatur of Owner/Agent Date
s
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
fool DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage f
Setbacks Front
Side L: R: L: R:
Rear
Building Height D
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved -70
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:
City of Northampton', \vim
Building Department
212 Main Street
Room 100 `'
Northampton, MA 01060 A"
phone 413-587-1240 Fax 413-587272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIt} A-SITE INFORMATION
1.1 Property Address:
400, 9 .+Q.�►.r.� �Y�t r •� 4 . ��
,
x
SECTI _N -.PROPERTY OW1+►E11SHIPIAt1THORI EI AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
�...►� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
�ON S STIMATED CONSTRUCTION.CQSTS
Item Estimated Cost(Dollars)to be OffiCi 1,Use Only
completed by permit applicant
1. Building 'qB°`��' (a) Building Permit Fee
2. Electrical '� a (b) Estimated Total C6st of
Construction from 6
3. Plumbing Building'Permitfee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+5) j Check Number
h For'Official Use Qnl
Building..Permit Nurriber: date Issued:
t�u�ldrng°C►rn�riisslonerllnspector of Buildings ' date
File#BP-2001-0043
APPLICANT/CONTACT PERSON BEHRENS MICHAEL&PAMELA
ADDRESS/PHONE 699 PARK HILL RD (413)586-0138 Q
PROPERTY LOCATION 699 PARK HILL RD
MAP 49 PARCEL 040 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: IN TALL 24'ABOVE GROUND 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
THEF
J,OtLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedibased 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
d% duoa��
Signature of Building Wicial 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.
699 PARK HILL RD BP-2001-0043
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:49-040 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Above ground pool BUILDING PERMIT
Permit# BP-2001-0043
Proiect# JS-2001-0071
Est.Cost: $3100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. 1): 84506.40 Owner: BEHRENS MICHAEL
Zoning: SR Applicant: BE H R E N S MICHAEL
AT. 699 PARK HILL RD
Applicant Address: Phone: Insurance:
699 PARK HILL RD (413) 586-0138 O
FLORENCEMA01062-971 1 ISSUED ON:7113100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 24' ABOVE GROUND 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 7/13/00 0:00:00 992 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
I
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i Carpentry, Design,and Renovation SHEET NO. / OF
L
55 Winterberry Lane CALCULATED BY 1 7e DATE �I _ - 111.11111_ Northampton, MA 01060 11_ _ _ _ 1111. 1111 1111
CHECKED BY DATE
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