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A E RIX-it AC4nccIto =
w , DEPARTME14T Of' BUILDP\10 INSPECTIONS
212 Main Strcet ' Muoicipal Building
Northampton, Mass. 01060
tip'ORICEIZ'S CO)UENSA- ON tVSURAhCE AFFIDAVIT
(li c�us:cJperrni flee) —-
�:ith a principal place of business residence at.
D 1oroe1
— (strM;�!'l/ci ty/stair/zi p)
do hereby certify, under the pains and penalties of perjury, that
( ) I a-m an employer providing the following Worker's comocnSZDC) cove agc for my
eluplovecs worjing on this job.
(laser Cocir c.)
(P 0 U C-Y N r)
( ) I am a sole proprietor, general contractor or homeowner (curie one) and have hired
the coouactors listed below who hive the f0HOW`inQ worker's caMnen Lion policies:
-- ('r4T'q m C of Coi'.r:ncio (1nR!r7nLti COill[;Sil)'/:�GUC-( ���UfTlr=�) (i_?:-)1i11:30i? 1711C)
of Cootractor) -- (lnssrancc Comoa-a)vPoticy NwDc�r) (Exnirzilon Date)
(Name of Contractor) (I-asurance_ Compao}/Policy Numbzr) (ExpLM6o9 Date)
(1`amc of Contractor) Rnsu=c-- Compaay/Pohcy Numb'-S) (E-x-pisation DaLc)
(mach��ocil<!xcL if veer-i.:) to ax!udr infocn,.aoo pczteiaing to.11�cc.o�) .
(1[} I am a sole propnetor and bave no one worLiDg for me.
( ) I am.a home owner performing all the work myself.
NOTE:ptclx_be-wire thlt.lwtL_]ctbcu3va >C� Hbo eraplay pc:om t d,r n_ca r I c rxiu t'orX on t d..e1-g of
cN mmoct th-- thrO l-Vj in wb3ch lhC bon,4,,ownc nCudC oe oc LIx Q'outYJ 2�p1-t11.CL1'•r1 tbCw L we�cxrally oeer:d�cil w be
c mployc-3 unCcr Lhc-oz tom ccampcas�lico Act(GL152.n 1(5)},applintioa by e bomcoavcr far.bc='--or pc'" it—Y--rd the
Icgal rtaaic of v c=ployoc under dro Works e,Coaapom.a.tioa Act
I undcrsund dw a copy of Lhu Qltcrocci my bo fot-A—ded Lo tba DW-ru—L cf In&ucid Modmt!MOO of L'�fa the
coverasc vcrif ezuoa and that L ttur to socwc`cover ngc uoder section 25 A of?.SQL 1 Sl can lc d to tha im uition of criminst peosllin
000iiAisg of s Gar of up to S I.300.00 artdtnf mmprisoon�cd of up to ooc ycnr r_ad a%it pcarhno io t5 form of a Stop W or4 Ordcr sad a
fim of 5100.00 r day tplim l me
Foe dcptruz+=-al u+o only
Permit Number
Lot I
Sign.iturc of Liocnscc/Pcrmittcc
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:_l Not Applicable ❑
Name of License Holder —0Qz:-1(0G
License Number
2«5 \ \mss` ��� �V-S� z-
Address Expiration Date
--, ,&- &W!;) -z%-3-- 0-)
Signature Telephone
U 3100,
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIG?N 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G'.L.c. 152,§2SC(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....... M 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 Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
C t - QP;8leTt—d 14 OFENMED c be
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [X] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ Sheet❑
yam,.
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 AID CONTRACTOR APPLIES FOR BUILDING PERMIT
l v<> as Owner of the subject property
hereby authorize to act on
my behalf, in all matt relative to work authorized by this building permit application.
Signature of ner 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.
K)1�'S �
Print Name
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
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 X _ 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._X._
IF YES, describe size, type and location:
Cltyy`'of Northampton
Bua8, ng Department
' 6 2040
2��. Main Street
oom 100
� c a ton, MAO 1060
r� ha ` 87.1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 11-SITE INFORMATION
This section rrete� if1
1.1 Property Address: y
Aap
' p
'r 1
, .
bane ��� re"rta District � �' �"
Elm St Dttict9`1Istrct
SECTION.2';- PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
5- J
- Pd l�„� /�. ��VG v
Name(Print) Curre t Mailin Add[e7 ss:
Telephone
Signature
2.2 Authorized Agent:
N ma (Print) Current Mailing Address:
16”, 0+ 3) z az3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
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) 3 ME-,, -o Check Number
T " Section For Official Use Only
Building Permit Number: _ Date Issued:
Signature:
Building Commissionerllnspec"tor of Buildings Date'
File#BP-2001-0381
APPLICANT/CONTACT PERSON KURT STAEB
ADDRESS/PHONE 2115 BAPTIST HILL RD (413)283-6983
PROPERTY LOCATION 5 KINGSLEY AVE
MAP 32C PARCEL 160 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REBUILD EXISTING ENTRY DECK&ROOF(SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 062766
3 sets of Plans/Plot Plan
THE FWLLOWING 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 Commiss' Permit from CB Architecture Committee
m zz
pO0
Signature of Building Officia Dat
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.
5 KINGSLEY AVE BP-2001-0381
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV:Block: 32C- 160 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0381
Project# JS-2001-0614
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groua KURT STAEB 062766
Lot Size(sq.ft.): 3005.64 Owner: MINTON JOSEPH E
Zoning.URC Applicant: KURT STAEB
AT: 5 KINGSLEY AVE
Applicant Address: Phone: Insurance:
2115 BAPTIST HILL RD (413) 283-6983
PALMERMA01069 ISSUED ON:10111100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD EXISTING ENTRY DECK & ROOF
(SAME FOOTPRINT)
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 10/11/00 0:00:00 3002 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo