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12C-080 (8)
I U ' I I j I I K I y I I U � x s 3 i U L NZ � h I t� I I J � i s _ I i • '� R 9a C n , CF- a-- X Y1 i I �o 1 1 ti �n i I r b rcF v� IL � titi • 6 ♦y 1i9,A� I � 1 Q C1tMlPT0 B � �aEd NCi�nbCt1E m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Builcling Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFMAVIT (licenserJpermitree) with a principal place of business/residence at: `.2 city/statrinp) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Date) O 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compalry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Hxpirntion Date) (Name of Contractor) (Insurance Company/Policy Number) (E%T ration Date) (attach addi60cnl short tfneocen,ry to include infrxmition pertaining to nu ooatma ra) i ( am a sole proprietor and have no one worEn g for me. ( ) I am a home owner performing all the work myself. NOTE:pteade be aware that while hcarowvm who employ pazom to do caiutmiacS cotrsuvctioa or rcpa ir work on a dwelling of not mote than throe units in which the homoowncr midcs or oa the gra:nds appurtcn alli thereto arc oot gco rally oomidcrtd to be employers under the wmkex.ration Act(GL152,=1(5))�application by n homcovkna for a Ucc—a pclmd may cvidcaoc the 1es4 aaars of an omployor under the Worker's C.omponution Act- I undwtand that a oopy of this uatemcnt miy be forwarded to tho Depwunca2 of Inaitstrial Aocideoi offioe of Insurweo for the oovcmx verifieatioa and that failum to secure covcmgo under section 25A of MGL 152 can lead to tba imposition of aims W pcnal>:es oousittin of a fine of up to S 1,500.00 ancVor imprison of up to one year and civil pendltia in the form of a Stop Work Order and a fins or:s 100.00 It clay t<gaiast mc. Foe dqurt-rn ut o only �f permit Number ' — Maph'� Lot# .tL y Si f Li e t2ce Late SECTION'S �q"v "U.CTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number / G � ' 1 i� -.2Q4� Address . Expiration Date F� — Ci Signature Telephone ue en C n rac`oorP pi? - Not Applicable ❑ Company Name Registration Number Expiration Date Telephone SECTION10 V1lORKERS',COMPENSATI0N 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....... 2�— No...... ❑ rn. 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 buildiny_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 SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing C1 Or Doors ❑ Accessory Bldg. ❑ Demolition❑ / ew Signs [ ] Decks [`]' Siding [ ] Other [ ] Brief Description of Proposed Work: Pvc . / c�' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative o Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet D 6a:If.NeW=iiduse and=orx`'addition to existing-housin7, complete=the follow `n : 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 Aj y 3 lC� yti nc�( as Owner of the subject property hereby authorize Ke- (1# N i U K S _ to act on my behalf, in all matters rela' ve to work authorized by this building permit application. Signature of Owner Date r _ 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 un er the pain and enalties of perjury. Print Name Date $ignature of Owner/Agent 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 D Frontage Setbacks Front Side L: R: Y,6 � L: /4�_' R: Rear Building Height Bldg. Square Footage % f Open Space�Footage % (Lot area minuarkin f�DDS #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO "�J 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 re any proposed changes to or additions of signs intended for the property ?YES No IF;YES, describe size, type and location: i df,"of, Northampton Building Department r 2.12 Main Street rSe r s i> pom 100 Wa Northampton, MA 01060 phone 41,�;�'87-1140 Fax 413-587-1272 Plo /SIteLLP 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` Map unit Zone Overlay District Elm St. District CB'District ' SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) °� Current Mailing Address: Aeeia9Y Telephone Signature 2.2 Authorized A nt://✓ cs /vA Name(Print) Current Mailing Address Sig ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only com feted by ermit applicant 1. Building (a) Building Permit Fee P 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) / q Check Number This ection For Official Use Only Building Permit Number: Date Issued:: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-0485 APPLICANT/CONTACT PERSON Kent Hicks ADDRESS/PHONE P O Box 119 (413)238-0122 PROPERTY LOCATION 11 MARC CIR MAP 12C PARCEL 080 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid ( ISO Tyj Construction• REBUILD EXISTING 17 X 9 PORCH TO 1T X 6' New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 066104 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION_PRESENTED: Approved [,/Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § 3 4. T Sys;j�6.4 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 C ssion Signature of Building Official 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. File#BP-2003-0485 APPLICANT/CONTACT PERSON Kent Hicks ADDRESS/PHONE P O Box 119 (413)238-0122 PROPERTY LOCATION 11 MARC CIR MAP 12C PARCEL 080 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid J` — Typeof Construction: REBUILD EXISTING 17 X 9 PORCH TO 17X 6' New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 066104 3 sets of Plans/Plot Plan F F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Perniit With 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 z 120aO L- Signature of Building Official 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. 11 MARC CIR BP-2003-0485 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-080 CITV0F NORTHAMPTON Lot: -001 Permit: Buildinl7 Category BUILDING PERMIT Permit# BP-2003.0485 Project# JS-2003-0814 Est. Cost: $15000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Kent Hicks 066104 Lot Size(sq ft.): 11499.84 Owner: BERTRAND GEORGE&SHIRLEY H Zoning URA Applicant: Kent-Hicks AT. 1.1 MARC CIR Applicant Address: Phone: Insurance: P O Box 119 (413) 238-0122 WORTH INGTONMA01098-0119 ISSUED ON:1215102 0:00:00 TO PERFORM THE FOLLOWING WORK:REBU I LD EXISTING 17 X 9 PORCH TO 17' X 6' POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: y164 E S ©k « C-a-V ,94, Driveway Final: Final: Final: Rough Frame:C)(f / —15-,:57 3 _64- Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: p K y-3 0 .03 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 12/5/02 0:00:00 5507 $50.00 2 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo