29-338 dD
bra
oo
r7
jd
I.Lj to Ll
CA
rj
f
� I
ri
� 7
H e�
i d
Z i j
i
cP o p cl
i
i
l
0
o
v 0 p
o
O
� � r
019O lU 'd ON
SNOU�dSN �J'i, I Ul�
jam} (� ( {�(� }{�
1 ( i 'Cl V v�1 V L 1 f 1 i I (g,? •J ni ,"'y}�d, r �.J` 65�
tA
j Ij k i i Q L� t L ia{ t"' 1✓�}' �y''
pi
n
19 u I H v o J
r ,
4(tW 1P�O
2� � e (r
'L1rtfja11yfoil
B 6 �:ssachnsctts
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
, o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I�
(liceusee�permi��ee)
with a principal place of business/residence at:
(phone#)
(stmeUcity/s7aie/aP)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the folow-ing worker's compensation coverage for my
employees working on this job:
(Insurance Company) (poky Number) (Expiration Daze)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Expirntion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (InsuraIICv Compaay/Poky Number) (Expiraton Daze)
(Name of Contractor) (Inau-ance Company/Poky Number) (Expiration Date)
(attach additice2l Shcc ifncccuary to inchidc informi.'ion pataiuing to all oCQtractor])
O I run a sole proprietor and have no one working for me.
f I am a home owner performing all the work myself.
NOTE:please be await that while homco"ncra who cmplay perom to k�ca ntcaanct corrstntctroa or repair work on a dwelliag of
not afore than throd units in which the homcuuvcr r=&n3 or on the pcun,d4 zppurteasnt tbaetc arc no(bczx Iy coosidcrrd to be
employers under the%vork&s c=*c^sation Act(GL152,:s 1(5)�apptitttion by a homoow=for a licrnx o<Per nd may cvrdcnoc the
legil ct2tLW of an employee undcrtho Workcc L Compmzation Act
I understand that s copy of this ciatcmcnt may bo forwarded to the Dcparta>co2 of Indiutrial Acodrn&Office of In-for the
oovaagc vcrificatiou and that failure to sxurt covtmv undcr scaioa 25A of MOL 152 can Icad to the iarposition of criminal pcnalt es
oomisti of a fine of up to S1,500.00 and/or imprisoumeut of tip to one year and civil penattia in the form of a Stop Work Order and a
firm of S100.00 a day igninst mc.
For dcparturs> uao only
permit Number
i Q map,,/ Lot;#
Sign of�sccVmittce e
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
*.'. .
now
RisteredHomeImpravement�ContrSctor.�� � s 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...... ❑
1�1.W
HomeMOwnerExempt>< n
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 buildinp- 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 _ _
r ,
SECTION 5 DESCC IPTION O'F=PROPOSED WORK(check 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: A.DZ) o7-0 'K k 0t-4 3A►C S fly- C(= "goo:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a, '!f New house and or.a"8dition to':existing-hou's"'ing.:complete he''followi k
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'OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize _ to act or,
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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.
�u�.i=mot -T V dDRJ 1 ?�C
Prin e
1u IQZ
41ina� ol 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 'tGO� K %to ` 0�
Frontage %O o
Setbacks Front 4o ' 4L
Side L: 40 R: LO L: 40 R:-2-0
Rear 40'
Z> l
Building Height
Bldg. Square Footage Ct G® %
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 1 Page 4 � and/or Document #
SN\%u %-Or \io
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:
r•
r ,
i v,of Northampton
ing Department
Main Street
10 2u02 J87 oom 100No pton, MA 01060 etsat a
240 Fax 413-587-1272 lotSite�P
Q ,�� Ot erSp @C2
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Iota Unit
o-
Z66e ;Overlay District r
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na t) Current-Mailing Address:
'�` 4-lEri S L-4 Telephone
Signal
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 y (a) Building Permit Fee
Loco To t5c®
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5) Check Number /5 06 This Section For Official Use Only
Building Permit Number: --037-111 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
� t
File#BP-2003-0041
APPLICANT/CONTACT PERSON DANIELS EUGENE J&MARY&EDWA
ADDRESS/PHONE 220 ACREBROOK DR (413)584-1615 Q
PROPERTY LOCATION 220 ACREBROOK DR
MAP 29 PARCEL 338 001 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 -
Typeof Construction: CONSTRUCT 16 X 12 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$wIATION PRESENTED:
Approved 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 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 Perniit from CB Architecture Committee
Permit from Elm Street Co ssion
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.
,pD BP-2003-0041
GIS#: COMMONWEALTH OF MASSACHUSETTS
*� CITY OF NORTHAMPTON
vii`ol
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0041
Project# JS-2003-0114
Est. Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 10628.64 Owner: DANIELS EUGENE J&MARY&EDWA
Zoning.URA Applicant: DANIELS EUGENE J & MARY & EDWA
AT. 220 ACREBROOK DR
Applicant Address: Phone: Insurance:
220 ACREBROOK DR (413) 584-1615-0
FLORENCEMA01062 ISSUED ON.7116102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X 12 DECK
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 7/16/02 0:00:00 2815 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo