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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
tt 'YORKER'S COMPENSATION INSURANCE AFFMAVIT
with a principal place of businesslresidence at:
p220 (phone#)
(kreet/ci ty/sta te/n p)
do hereby certify, under the pains and penalties of penury, that:
O I am an employer providing the following worker's compensation coverage for my
employees workt-ing on this job:
(1asu.rance Company) (Policy Number) (Expir-tion Dale)
I am a sole proprietor, general contr�or omeope��els circle one) and have hired
e contractors kssted below who have the fon ompensa tion policies:
use &As lea SUIIjvaLA �nS iwu-e �-
(Nnmc of Contractor) (Insurance Compauy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaily/Poky Number) (ExTp ration Date)
(Name of Contractor) (Insurance Comparry/Pohcy Number) (Ex-pimbon Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifncccau to include iaformiboa pertaining to all 0o ctors)
O 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 aware that whilo hotncownaa who employ paiom to do rrt�;.Aca u r was run on or repairµuric on a dwcLling of
not more than throo units in which the homoowow r=dcs or oa the grouad,apputten thereto arc no(Ecrxaally oocs:dcrtd to be
employco under the worms maVc nation Act(GL152,a 1(5))�application by a homcowna for a license a pcsmii may cvidcnoc the
legal autua of an employer under the wockcls compamation Ac(.
I understand that a copy of this etatcmmi may bo forwarded to tho Departaxa(of InduzUial Accidca&Offioe of Imursoco for the
coverage va-&C160a and that failure to soa=covcrngv and r sociioa 25A of MOL 152 can lead to the imposition of--W Pen Wts
ooasiating of a fine of up to S 1,500.00 end/or iatprisos>mctlt of up to one year and evil pcaalti a in the form of a Stop Work OrdG and a
firm of 5100.00 a day against Mr
For dcpu�l usb only
Permit NumbQ
Nbla ll Lot#
3 Sign tture of LiccnscdPermittee e
SECTIQN.B CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
L(, &1k S�f G P{_, _ w889
Address Expiration Date
Signature Telephone
Not Applicable ❑
gRe °r Hm a r�ement Can r rte
Sawn
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 completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of th ilding permit.
Signed Affidavit Attached Yes....... No...... ❑
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 Z nin Laws and St to of Massachusetts General Laws Annotated.
Homeowner Signature 4-A4
I
SECTIONS DESCR',I PT'IONWQF �k PROPOSED WORK�(che 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: V a `4f nLuv CKWInj Vim L,�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet D
6a IfNew` t�a�'se"" a�idoraidd�tion to'ez�sfing.h'ous`ing :cornple�eth�££f"ol"lowl.ri :
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. Z-4 r Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Ene gy 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 ping regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a„ "OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWN ERS.AGENT OR��CQNTRACTOR APPLIES FOR BUILDING PERMIT
I, K� 1Nltih �"L as Owner of the subject property
hereby authorize to act on
my be alf, in all ma ters r ative to work authorized by this building permit application.
zhg Z
Signature of Owner Date
yu Z as Owner/Authorized Agent
hereby declare that the statem nts 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.
V-S\)(0 J , ��-
Pri�tN am e
ZzBaz-
Signature of Owner/Agent 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
1^ �f Building Department
Lot Size 314 II�L` c
Frontage 60 /
Setbacks Front 1t001 tokil 5Am4
Side L: 9W R: L: R:
t2.o/ ILO-1
Rear i -Zlo I
Building Height .yZ A60ve Qmv,
Bldg. Square Footage 36 t %
Open Space Footage % /J `
(Lot area minus bldg&paved U
arkin )
#of Parking Spaces
Fill:
volume&Location
A. Has a Spe al 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 D ument #
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 Comm.ssion?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YE;Sde s e size, type and location:
D. A here any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
9 <
City of Northampton ,
Department Gr
in Street
100
Northa n, MA 01060 ,
i FgoM41A8 4 Fax 413-587.1272
0 rpeaif�
PPL N."TtO
O Q��VSt'{rff WCT ER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sectionto be completed b� ff ce
Map Lota :art r
Zone overlay District
Elm St. District CB DIStrict "
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) CurrEt t/�ail ddress:
k�o — Telephone
j Signature
2.2 Authorized Agent:
I
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted b permit applicant
1. Building a B
uilding Permit Fee
2. Electrical P�0 I (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 ® -
This Section For Official Use Only
Building Permit Number: ol) — Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0736
+ APPLICANT/CONTACT PERSON KRUMPHOLZ KEVIN J&BRENDA L
ADDRESS/PHONE 395 RYAN RD (413) 586-4910()
PROPERTY LOCATION 395 RYAN RD
MAP 29 PARCEL«553 001 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 _
T_ypeof Construction: INSTALL 2T ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
ROWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION PRESENTED:
roved 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: §
Finding Special Perniit 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 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.
395 RYAN RD BP-2002-0736
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma lock: 29-553 CITY OF NORTHAMPTON
Lot:-001
Permit: oi u A I n d
Category: Above ground pool BUILDING PERMIT
Permit# BP-2002-0736
Project# JS-2002.1209
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sg. ft.): 20124.72 Owner: KRUMPHOLZ KEVIN J&BRENDA L
Zoninpz:URA/WSP A-pplicant: KRUMPHOLZ KEVIN J & BRENDA L
AT: 395 RYAN RD
Applicant Address: Phone: Insurance:
395 RYAN RD (413) 586-4910 ()
FLORENCEMA01062 ISSUED ON:318102 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL 27' ABOVE GROU ND POOL
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/8/02 0:00:00 4950 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo