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INSPECTIONS '
NORTHAMPTON, 01060
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` ')' —y °. ' — � i. D EPARTMENT OP BUILDING I NSPECTIONS -_--...1.1 _
c9 _
212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE Al +`FU)AVTT
(licenseeipermittce)
with a principal place of business/residence at:
2- _7 r. 5 /c' 0
/ _'_' f_"�.�� ,iv" e5� (phone #)
(. •- city /statcirip)
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)
I am a sole proprietor, general contractor homeowner (cir e one) and have hired
the contractors listed below who have the following wor e s compensation policies:
(Name of Contractor) � ce Company/Policy Number) (Expiration Date)
/' `
(Name of Cont (actor) J (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(attach additions shcc( ifne:cessay to include information pertaining to all cosier tors)
( ) I am a sole proprietor and have no one w orking for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that whilc homeowners who employ p ens to do maintenance, wns:rucaon or repair work on a dwelling of
not more than throe units in which the homeowner resides or oa the grounds appurtenant thereto arc not generally considered to be
employers under the worker's compensation Act (GL152,m 1(5)), application by a homeowner for a license or permit may evidence the
legal stable of an employer under the Worker's Compensation. Aot
I node:ra ad that a Dopy of this a tatcmcat may be forwarded to rho Dcpartamt of Industrial Accidents' Office of Iasursnoe for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties ,
coon istiag of a fine of up to S1 500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
firm of 3100.043 a day against Inc.
•
For dcparunto& we only
Permit Number
MaIrt Lot # -----].
Signature of Licensee/Permittee late - ,
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.GL. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid<
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) famili
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act:
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 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
•
SECTION 5- D SCRIPTION OF PROPQSEP all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other
Brief Description of Proposed Work:_ � ��7 i �'� i`1 ��c f1 ,/E- t A 7 / %7:; S
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?
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 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES 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 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 N a m e _
Signore of Owner / Agent----_--- - -- Date
1.
A
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
■
"11 ; . Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lo Size
• ntage
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
\1 1 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
L 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:
A
r E C [E II E: ' - --1, -- 2' , - --, ;-.
5. of Northampton S t sxof Z , !: : � ,
i K1 B i�g Department Our 0ut'0 i ° • " a �
1 , ` 2 u 2001 L 2 Main Street ` A ai t
Room 100 Via rlWell Av abilt , ,.,� °� � 3
fib. = a
tharr.pton, MA 01060 1Tw Sets!of;Str c ra
DEPT OF BUIL_DIL�G_INSPE �1�,� ^;itt�t; .0
NORTNAMM lAe0f0 15 -1240 Fax 413 - 587 -1272 Plot /Site Plans
Qt r Sp ec fy •, - 41
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by, office
/4 l / c , Map : Lot ) ,, U nit
Zone ]] i Overlay District
Elm St. District `, CB District
SECTION 2 - PROPERTY OWNIERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
T /,,t, �...' %— . /4 7 7 S / j •i j 7 c � t i
Name (Paint-}- L,! ' - - - - currpnt Mailins Address:
�.r. z-:`,._ Telephone
Signature
2.2 Authorized Agent:
t .
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
At ' -' 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 = (1 + 2 + 3 + 4 + 5) Check Number �C�
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings,, Date
File # BP- 2001 -1123
APPLICANT /CONTACT PERSON JAMES STEVEN
ADDRESS/PHONE 122 KING ST (413) 552 -1002 0
PROPERTY LOCATION 122 KING ST
MAP 31B PARCEL 144 ZONE NB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c.SC Ce��
Typeof Construction: BATHROOM UPDATE ( FIXTURES /SHEETROCK), KITCHEN COUNTERS
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 LLOWING 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 Commis • n Permit from CB Architecture Committee
—riot Z 2429
I /
Signature of Building Offic 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.
4 , 6 BP- 2001 -1123
COMMONWEALTH OF MASSACHUSETTS
`B1ocic a 3i ' 1 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Non structural interior renovations BUILDING PERMIT
Permit# BP- 2001 -1123
Project # JS- 2001 -1974
Est. Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 8363.52 Owner: JAMES STEVEN
Zoning: NB Applicant: JAMESTEVEN
AT: 122 KING ST
Applicant Address: Phone: Insurance:
122 KING ST (413) 552 -1002 0
NORTHAMPTONMA01060 ISSUED ON:6/29/01 0:00:00
TO PERFORM THE FOLLOWING WORK: BATHROOM UPDATE
FIXTURES /SHEETROCK), KITCHEN COUNTERS
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 6/29/010:00:00 340 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo