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29-342 (3) t.. 'A � s f X _ ` �l i t CD clq C� p� C'N ! !W n1 _ 49 > a ,,y A lab s i M r, ( ,177 MAY 3 i a � ,-n _ -77 -r N r. . G L —r7 - , S I ID n rn N i f $r" MAY 2 t RON- ;r ! O' ?O F rF (rzf�3 of 3K orillalliFtoll - — _- ��116Arh ncrf(a - -- DEPARTMENT OF [IUILDING INSPECTIONS — 212 Main Street ' Municipal DL1ilding Northampton, Mass. 01060 WORKEWS COK-PENSATION INSURANCE AFFMANrIT ,- (h scxJ�xrrn l tt ti) vrith a principal place of business/residence at: I/ lion C x (SCiti::/Q iy!Stn1C�Z]p) do hereby certify, udder the pains and penalties of per}ury, tha t ( ) I am an employer providing the following vm"ixl's colnnensa�on coverage for Iny elnplcyces wormy, on this ),nh (Insu-ran� Comr-,ry) (PoLc. N��irr) (L piraaon Date) 1 am a sole propnetor, general contractor or hor�ieowner (circle one) a_nd have hired tee contractors listed below who love the iollow'inQ workei's co©nensation policies_ (Name of Contractor) Date) (Name of Con(ractor) Ojn d ancr, ComoallwPolicr (Bpimuon Date) (Name of Connector)-- — (Insurance Companyfpotic- Nimr-1),r) (Expfmuon Date) (Name of Contractor) (Insu=c-- Compaay/Poky Number) (L\piranon Dart) (attach additional z?acct ifoocr_z to mc?uc±-iafocmv.�oo pccuunanc to e11 Enron) O I am a sole propnetor and have no one wor-Lng for me. ( ) I am a home owner performing aH the work myself. NOTE:plcsc be aware tit w�—,Jo hoo -Dc"u,�o ploy porous to do r-j.: cl oo cr rcpa r work on s d,--t-a of oot mace tb.n Lhr o units in which ttr bai»o�vc rcn&3 or oa the V,3, xis zm t cn uhcoto ac oo(gcncralty to be employers tnsdcr the wurkrts oo=pc=s-:iicu Act(GL152,z 1(5)�appticatioo by n homoowucr fore bcm,,-a permit may c-rdcnoc the Ieg l rt-htu of an amployoc under tho Worico'a Comp�Act_ t undcrsiiad tb,i a oopy of this rt t.csc i may 1w focwnrclnd to Lbo pcpartmmx of Indusrid A. d.t&Offioc of Ina..v.noc for the covcrxjgc vaif catioc and that L-ilure to uauc oovcr under-,Moa 25A of MOL 152 nn Iced to the imposiiioa of aunmA penalties ooaus6iag of a fine of up to S 1,�D0.o0 ertdla anPruo®cut of up to ooc year end civil pmahio in the form of a Stop Work Order end a fcm of sloo.o0 r day tsainsl me For dl q,.n..,r.y.l�ui only ------- — / �OfLasc�xv�/ cr mi t N trtn txr i — e SECTION 8-CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone t. ....., 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ W 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 CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks k'] Siding[ ] Other [ ] Brief Description of Proposed Work: / 'L � �G-dv, c -Pt / Gv�.a. `o+^ G��ddu Alteration of existing bedroom Yes _ No Adding new bedroom Yes ✓ No G� ddr Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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? 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 I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner 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. Print Name ^ / Signatur of ner/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 Oz' ©✓ f:1 Frontage Setbacks Front 2 Side L: 11-19, 3 R: L.q f R:3/ JS5, Rear .511 �3 �/ Building Height ( 5 15 ` Bldg. Square Footage % /4999- 9- 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 _ Z 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. 7ere any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: I Northampton ly Q I tepartment 21: a i n Street / ep £ MN 2w Aum 100 � r/1Nt �� ✓�, ; � y Northa ° pton, MA 01062 Tree e 1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This section`` 6,be Completed by office flap Lot -Unit Zone - , , ,. Overlay District Elm St.District CB District' SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: m(2N �/��UC, - ,�/Z. /10 &z/S z-?A5 «mac kr�kr Name(Print) Current Mailin Address: tom, �Yi, Telephone Signatur 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 (a) Building Permit Fee i 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing A-114 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection N�A 6. Total =(1 + 2 + 3 +4 + 5) Check Number 7 This Section For Official Use Only Building Permit Number: d Date Issued: Signature: c� Building Commissioner/Inspector of Buildings Date 000_� 4 BP-2000-0970 APPLICANT/CONTACT PERSON NIQUETTE RAYMOND H&JEAN A ADDRESS/PHONE 110 AUSTIN CIR qq—_;p0(o PROPERTY LOCATION 110 AUSTIN CIR MAP 29 PARCEL 342 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 4 T_ypeof Construction: CONSTRUCT 12 X 14 DECK 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 F OLLOWING 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 Co sion Permit from CB Architecture Committee Signature of Building flicial Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning pA requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. 'TIO AUSTIN CIR BP-2000-0970 GIS#: COMMONWEALTH OF MASSACHUSETTS MiBlock:29-342 CITY OF NORTHAMPTON ot: -001 Permit: Buildinq Categoa:Deck Addition BUILDING PERMIT Permit# BP-2000-0970 Project# JS-2000-1774 Est.Cost: $6000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sq. ft.): 11979.00 Owner: NIQUETTE RAYMOND H&JEAN A Zoning URA Applicant: NIQUETTE RAYMOND H & JEAN A AT. 110 AUSTIN CIR Applicant Address: Phone: Insurance: 110 AUSTIN CIR (413) 584-3006 O FLORENCEMA01062 ISSUED ON.514100 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 14 DECK 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 si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/4/00 0:00:00 1837 $50.00 ate" 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo