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10B-103 (2)
i ` 4�t�PT0 .�\ �O a B . c litf4ACll I(SCt14 DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 �~ WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licensee/permittee} with a principal place of business/residence at: (phone#) (&t=Ucity/stablerp) 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) I am a sole proprietor, general contractor o homeowner J cle one) and have hired th contractors listed below who have the follo compensation policies: (Name of Contractor) (Insurance ornpany/Policy Number) (Expiration Date) (Name of Contractor) (insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (roar ante Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioazl shoot ifneocn to iochi&infonnation pertaining to all ooatradon) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be away:that v&Uo homcownm who employ periom to do njn_ �000:suzion or icpair work on a dwelling of not morn than three units in winch the honj6owncr resides oc oo the grounds appurtenaai thm-eto arc oo(generally oomidacd to be employers under the twrket's coarpcns4oa Act(GL152,ss 1(5)�application by a homcow na for a liccase cc permit may-id—the legal slaw of an amployoc under the Wockoee Compomation Act I understand that a copy of this etalemmi may bo forwarded to the Depactaicnt of Indaufial Aaadm&O$oo of Imuranm for tho covaage va ifiastioa and that failure to actors co%vnLp under section 25A of MGL 152 can lead to the imposition of criminal penalties oomisting of a fine of up to S1,500.00 ZnNor imprisoaasari of tip to orx year and ava pemlties in the form of a Step Work order and a fum of S 100.00 a day ag&insl m- For dq:u�uao only G►) ell "N-01 permit Number Map4 Lot# Stgnaturt:of Liccn_secypermittee 2 _ _ p, rtt i a�3. N ECTONC�NSTRlJC710N,SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9 " e�ffe e wont a mpro��men �" n rac o 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 affidE. 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 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 L cal Zoning L and Stat o Massachusetts General Laws Annotated. Homeowner Signature �` Ej • _ J . Fill"Wil, �t SECTION D SCRIPOF� PI MROPOSE�iNORK check alb a licable iw 3hh'ids kAb° ssyy6 h l94%b SP'3W '9k k'.d' � Y 3ai�'`ax x a �t t, ? 7 �wrn New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ]]J Decks [ ] Siding[ ] Other Brief Description of Proposed Work: s Alteration of existing bedroom Yes No Adding bedroom Yes �No Attached Narrative❑ Renovating unfinished basement Yes ✓No Plans Attached Roll ❑- Sheet❑ sa f Ne o ise i"d or tldittone#o ez1st-1fF us n�. comialefi" #he.`fol`lov�iin : 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 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 " IWNERjALITHORIZATION TO BE COMPLETED WHEN o1NNE SAG NTyOR C0N7f�ACTOR APPLIES',FOR BUILDIN,G.PERMlt as Owner of the subject proper hereby authorize to act my behalf, in all matters relative to work authorized by this building permit application. "Signature ner Date as Owner/Authorized Agent hereby declare that the statements and ififormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t e pains and enalties of per* ry. ehk W Print Name wl v - 2-6- e-o Signature o Owner/Agent Date i 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 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: i.; Ll 1I12 of Northampton ding Department Main Street e r e Room 100 U'-NI�r K110INGINSPECT1oNS ort ampton, MA 01060 e s o 7-1240 Fax 413-587-1272 a otl �te s APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section toPbecompleted byff�ce 1.1 Property Address: OW EImSt. District '' CB District SECTION - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner f Record- n e dross Name(Pri t) Current Mailing Ad ess: ^,t=. q(3- J7rK- Y16 0/Z- Telephone Sig at re 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 .� e- (a) Building Permit Fee 0 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) 0 dam.- Check Number This Section For Official Use Only Buitdtng PermitNumber Date Issued: t Sligna Pre Bu+1d�rB:Commissio►er/Inspector ofiButldings ©ate 9 File#BP-2002-0460 APPLICANT/CONTACT PERSON LYNDS KENNETH W&KAREN A ADDRESS/PHONE 71 RESERVOIR RD (413)584-4662 () PROPERTY LOCATION 71 RESERVOIR RD MAP IOB PARCEL 103 001 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Typeof Construction: REPLACE EXISTING DAMAGED PORCH& STRIP& SHINGLE ROOF 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF09RMATION 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 Signature of Building fcial 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. r w' 1 F?RV01kRh BP-2002-0460 CIS#: COMMONWEALTH OF MASSACHUSETTS p Block: 10B- 103 CITY OF NORTHAMPTON Lot: -001 Permit: BuiIc ing Category:Non structural interior renovations BUILDING PERMIT Permit BP-2002-0460 Project# JS-2002-0698 Est. Cost: $10000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq. ft.): 51400.80 Owner: LYNDS KENNETH W&KAREN A Zoning: RR Applicant: LYNDS KENNETH W & KAREN A AT. 71 RESERVOIR RD Applicant Address: Phone: Insurance: 71 RESERVOIR RD (413) 584-4662 O LEEDSMA01053 ISSUED ON.10/26/01 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE EXISTING DAMAGED PORCH & STRIP & SHINGLE ROOF 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/26/01 0:00:00 444052595 $150.00 212 Main Street, Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo