32C-214 (4) ___.__.
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9 Bcsan'cllnsrtta
DEPARTMENT OF BUIL)rNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AT, ' AVIT
(licenserJpermittec)
with a principal place of business/residence at:
_(phoney#)
(st-c Ucity/statrJzip)
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:
(Insura-nec Company) (Policy Number) (Expiration Date)
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/Policy Number) (E)#ration Date)
(Name of Coutractor) (Insurance Compauy/Poticy Nurnbcr) (Expiration Date)
(Name of Contractor) (Insu=cce Comparey/Poticy Nurnlx r) (E,i-piration Date)
(Name of Contractor) gnszlrana; Company/Policy Numtrvr) (Expiration Date)
(anach addrtioaal ltcc if nocc—Ty to include information pertaiaing to all oo rsad4r�)
O I am a sole proprietor and have no one working for me.
( ) I am a borne owner performing all the work myself.
NOTE:ptcaac Ix awarc that whilc homco Ai-,cca who cmplay peram to do msiutc=cf�co oa or repair work on a dwclling of
not more than thno units in w#rids the ho noowvcr raider or oa the pounds appurtenant thado arc Oct Ccncrally oorJidatd to be
employers under the%vo kcils axnpersation Act(GL152-u 1(5)�application by a horncow-ocr for a l erne or pclrnit may evidence the
It8+1 ctxb-w of an employer under tho Wocicoda Compenulioa Act
I understand dial a copy of this ctntcmmt may be forwarded to tho Dcpnrtmr of lodwfriel Am6&—s&Of Eoo of Invuwoo for the
covcrr<gc unification and that failure to r=trc covcrngo undcr scctioa 25A of MOL 152 can Icad to the imposition of criminal penalties
comistiag of n fine of up to S 1.500.00 and/or im{risoma rd of up to one year and civil penalties in the form of it Stop Work Ordc and a
fim of 5100.00 1 day agyinsl Mr-
- For dcprrtmaew uio oafy
Permit Number
Map<I_____—.Lot
Sig-tt at of Liccnsce/Permittce e
NNNUMMONNOW
SECTION 8-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Rre„5tt' .aRF.d^ ,.e,�y Ytl �. r..ret R'$ 4° -,.i� ��'St�yq S AS i ! •A
Re is"teretl otif—eTmprovementfCbntractor "y� � �, .r. �� x ...,.. ,� Not Applicable ❑
� g
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...... ❑
_ - oFM ®� one . ems. "' ,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 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 n(.iI1�N d 20,�(tp
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all apaiicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: (y X f1) ICI 6�dd 0 cy
Alteration of existing bedroom Yes L-----No Adding new bedroom Yes r No
Attached Narrative D Renovating unfinished basement Yes k=`No
Plans Attached Roll [I - Sheet❑
sa. If�New�housea'�'itl�or�aiidif'ion=to=existing"Fiousini7,'_comple'testhefollowin'�:
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-IOWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS.AGENT OR,CONTRACTOR APPLIES:FOR BUILDING PERMIT
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
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 'g 8 ct v
Frontage
Setbacks Front G
Side L:_'E_�._i014R:_` L:a?5 R:
Rear
Building Height
Bldg. Square FootageO %
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 L------
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 sigrts intended for the property ?YES
No
IF-YES, describe size, type and location:
Cityof Northampton Spat s Per
r, ffC HT91Department �G�urb C u ID v
pin Street ewerfSep is _ ato
pim 100 Wa er%WeI( v
Pgatl i n, MA 01060 Two Sets o St � rff a ,
1 �
p88
hone 413-5 .12 0 Fax 413.587-1272 Plot/Site¢Plaris p
Other Specify
UL
tAPPLICIt'1 Vi 4 = TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section.to bei completed by-office
�� Map Lot Unit
)Jr!tS kD
/fey _ r 'C&n Zone Overlay District
! Y /)l Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
n� lic I /-t /,�- �r /,s-/� X11 rY fhcin r ,7
Nam (Print) Current Mailing Address:
Telephone _yy
Signature USA_ �0 G
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 ap licant
1. Building % (a) Building Permit Fee
Shed (o . /6)
2. Elecirical (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 144V f
This Section For Official Use Only
Building Permit Number: Date Issued:
LSignature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0389
APPLICANT/CONTACT PERSON EDWARDS LYNNE K
ADDRESS/PHONE P O BOX 1513 (413)585-9897 Q
PROPERTY LOCATION 35 HOLYOKE ST
MAP 32C PARCEL 214 001 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
T_ypeof Construction: ERECT 10 X 6 SHED
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
INFOMATION 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 Permit from CB Architecture Committee
Permit from Elm Street ssion
d -L Zo 0
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.
35 HOLYOKE ST BP-2003-0389
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 32C-214 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0389
Project# JS-2003-0658
Est.Cost: $1250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 3789_72 Owner: EDWARDS LYNNE K
Zoning:URC Applicant: E D WA R D S LYNNE K
AT. 35 HOLYOKE ST
Applicant Address: Phone: Insurance:
P O BOX 1513 (413) 585-9897_Q
NORTHAMPTON MAO 1061 ISSUED ON:10123102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 6 SHED
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: Q k //`13-0,3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF
ANY OF ITS RULES AND REGULATIONS. ,., -°L="
Certificate of Occupant Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/23/02 0:00:00 140
140 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo