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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street * Municipal Buildm1f;
i, orthampton, Mass. 01060
%Y01' E,R'S CO.,MT NSATION INSTJVANCYi :1h'FIDAVIT
i. L �r�y -
- N�useJpernu tter.)
th place of buS' 11eSsJresidence at:
— -L►-L--(�iC�ZrL- 1 -, '.�5 ; n c_ic5- (phc t.-} �J��-S£�✓-�17sz'
(street/city/statr/�p?
do hereby certify, under the pains and penalties of penury .hat
( ) I ,m an employer providing the following ,;w)kers compensation coverage for my
employees worl.-ing on flu's job-.
(IiL1:11�_1... CorlT.an}) (Polio iv,LSE:cr) (T�1`pir�aon Date)
( 1 I and a sole proprietor general coniTactor or homeowner (c rcle one) and have hilerd
t-he contractors hsteQ below who have Pile follmNiF1g v10rk1',I s CO[`ii7enti3tl0, poll les:
(Name o:Coninctor) (Insurance Company/lolicf Nutnb-_) (H'xi Tv,tioa Date)
(Name of Contractor) (Insurance Company/Policy N'mnL-:r) (Expiration Date)
(Name of Contractor) J=rancc Company/Policy Numtkr) (Expiration Date)
(Nmne of Contractor) (Inmuanc:, Comp-ny/Poky Date)
(attadl itiuul rlxct if nc,��ry tp p�--taiaing to all cxltrm iora)
(�I mn a sole proprietor and have no one wort trig for me.
O I am a home owner performing all the work myself.
NOTE:picas be awarc that�vltilc horrcowlx_rs who crn Ivy perzo^a%to d) d«clling of
not mere than duce units in M dt tIx midea or on L'I't grou xh appurtcn.rt ihacio r 2 n X 'lty eocJidcrud to be
employers under the%Y'cC rr'a cxxtpc cation Art(GL152,-n 1(5)�application by a he mco"ncr for Licrnx ct pctmd may cv do xc the
lcgil ctantc of an amployor undor thn Workcc r,Co�tion.ALL
I undc^cti d thit a copy of this ctatcmn t may bo fofw mli J to tbo Uc{xut-vcn2 of Ir izizial A.cadcnt Ofrioo of tirurarxn for tfn
eoverag-e vaificatioo anal ULu.f Lure to sccurc covcmv tuxix Soctioa 25A of MGL 152 can lmd to the ullposition of cr m ul Acct+hies
eomisting of a fine of up to 51,500.00 atr:Vor inrprisoamcc»of up to one yr�tr and chil perultiu in the form of a Stop Work Onic and a
fine c(5100.00 a day again°.t mr-
Foc-dq;utnx z:a1 uao only
perrait Numbes
LTT ^
ilt K
signature of Li scrip ttce e
p `
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :_ LRP-14'y J- YCAIT'`'IY G�t q /°�,6 _
License Number
fr1 1,L A -ilZec PO, 030x 1 L0- S /?? D/vJ� ---- `'7.12
Address Expiration Date
Si nature (/ Telephone
RN pP
Not Applicable El 9 �Registered Hofne Improvem`ent�Coritractor. �' .., , �-d
-
Company Name Registration Number
_ 1/ 1 W,97r,/7- Si n„O4.4 `I
Address Expiration Date
Telephone V/3 -57S '1- L/-7 SZ
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...... ❑
11. =#HomefrOwrien,, xemp ton
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
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing I
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:— STP,410 '511141 1c5 0,-/— 6/j"6X_ fiD/Z/hC-Q, , ApPi'i-Y klOt l 51YIAI"eS
Alteration of existing bedroom Yes___ No Adding new bedroom Yes No
Attached Narrative U Renovating unfinished basement Yes No
Plans Attached Roll N - Sheet U
6a. if New, house°arid or-'addition to existing housing complete the following:
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
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
I hereby authorize 4 14—H to act on
my behalf, in all matters relat ve to ork authorized by this building permit application.
Sig to e of Owner Date
y _% y f, .SL%{ as Owner/Authorized Agent
[hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
nowledge and belief.
Signed under the pains and penalties of perjury.
1-na,ay J Y�NTSGff
Print Name
V1
Signature of Owner/A nt V V Date
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arking)
#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 S atusofPer 1
Building Department Cu b Gutlpew t
212 Main Street Sewer/SetcAva�lafJi
Room 100 W��rlWetl Av5100 1iW d � r
Northampton, MA 01060 Tw019etsof5try6tura �a s
phone 413-587-1240 Fax 413-587-12 2 PlotlSite Plari`s 5 y . .
k
Otie'r Spectfy'J �
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 `Lot ' Unit
Ael?f G' Zone Overlay District
Elm St. District" CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 62—
3014 by A-K CO R444 C-i C-5 1rvo1'g Al PI&/-_gov t)�_ #41M/9
Name(P t) Current Mailing Address:
Telephone
Signat
2.2 Authorized Agent_
Name(Print) Current Mailing Address:
Signature % Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building 411 —d (a) Building Permit Fee
2. Electrical y (b) Estimated Total Cost of
Construction from 6
rk 3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t- BP-2002-0310
CIS#: COMMONWEALTH OF MASSACHUSETTS
rp CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0310
Project# JS-2002-0471
Est.Cost: $1500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Yentsch 103986
Lot Size(sa.ft.): 11151 .3 6 Owner: WILLS CYNTHIA J&JOHN B
Zoniniz:URA Applicant. Larry Yentsch
AT: 48 INDIAN HILL
Applicant Address: Phone: Insurance:
P O BOX 120 (413) 584-4750
LE ED SM A0105 3 ISSUED ON.-9119101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF DORMER
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:
Driveway Final:
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 si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/19/010:00:00 1333 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo