32C-231 (8) F�o ��t�o�`Q. �I�7 ,L7� �IIZf�Jt3111�J�II11
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DEPARTMENT OF BUILDR\TG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOR]tER'S COMP'ENSATION INSURANCE AFUIMAVrr
--- (li ccvsaJpenn)tt�)
�VI th a principal place of business/r idence at:
Y\Q-, Aq—,
(m ildtyIn2 IC-In p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following wori;eT's colnnensanon covet-age for Inv
eluployees wor-king on this job_
a
v � �_� t-��ir�tionDale
O I ant a sole propnetor or homeowner (circie one) and have hired
the contractors listed below who have the following workers compensation pokes.
(Name of Contmctor) (Insurance CornpanyiPoLic-� (Expinmon Date)
(Name of Contractor) (Inszlrance Companyi?ohcy Nu=n ,-r) n Date)
(Name of Contractor) (Insurance CompaBylPokq, Nulnbu) (Expl—M000 Date)
— (Name of Contractor) (Lmnuancc Company/Policy Number) (Expuranon Date)
(a—h a63i6 oml +mot if ncocsury to mclud`i f'D m oo t><rtaining to all oodrnf-'..on)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myseff.
NOTE:please be awam thxi wino homcowvcrs who employ pa-om to do mm=cnaao,oom:r o0 or repair work cc a d.velli:s of
not moeo than drroo twits in which the 6omooavcr r=dc�«oo the Vix l appurtcnarri thccto arc oo(&cvcrn coosidacd to be
employcn under the vwo i oope:satioa Act(GI152-=1(5)},apptit zon by a hom oavcr for a Uccusc a per n nuy-16— he
Ie$il vtnti of an amployec under dh wockr js compemalion Acc
I undcrrtand thxt a ocpy of thi,—t—ccd m y bo forw—i d to tho Dcpartmaax of Induz d Ac drnty C ffioo of rmrrinco for the
covaxgc vcrificmioo and that f--1=to aazue covrrn under sccuon 25A of MGL 152 can Icad to the imp05,tioa ofaunmal pcm1-
cx>austurg of a fine of up to S 1.500.00 arxl/«=Tn-jvo® of up to ow year and civil penahia in the focm of a Slop work Order and a
fim o(S I00.00 A day I&uon mc_
Fo, ooly
f crinrl NumnC7
(�l..t 1vLtpt,' Lot _
Signature of L i ccnscc c mii �??�
�WTION 8-CONSTRUCTION SERVICES
Licensed Construction Supervisor: Not Applicable f❑
Name of License Holder
License Number
Address Expiration Date
� s o r o
Signature Telephone
f ... Not Applicable licable ❑
a- ��
Company Name Registration Number
lss m om . �1 ~ A-
Address Expiration Date
IVATelephone= �
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.
�Wvned 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 fob 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, tjandLo a]Zoni ng aw�an tate/`of Massachusetts General Laws Annotated.
Homeowner Signature . /
V
TION 5-DESCRIPTION OF PROPOSED)5 ORK(check all applicable)'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors P'
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Vf Other [ ]
Brief Description of Proposed Work: NtoLwart,
Alteration of existing bedroom Yes No Adding new bedroom Yes V No
Attached Narrative❑ Renovating unfinished basement Yes Vl' No
Plans Attached Roll ❑ - Sheet❑
6a', I U `0 1 ! '`8 .s " >C m 1 - a fin]lowing:
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
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 Y 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,__t— oc�' a ".,\,% )J an-_ �2 _ as Owner of the subject property
hereby authorize to act on
m b , in all matters re tive to ork uthorized 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.
,igned 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
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 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:
City of Northampton s \�
Building Department ` ' '
212 Main Street ` FEZ �W $vx
Room 100 ,
Northampton, MA 01062 o sae
phone 413-587-1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section tai be completed by office
1.1 Property Address:
Map � Lot t _,✓�,�., Unit
Zone __ Overlay'District
Elm St.District CB District
SECTION 2- PROPERTY OWNERS HIP/AUTHORIZED=AGENT
2.1 Owner of Record:
me(Pr' Current cling Address:
Telephone
ign re
2.2 Authorized Agent: NCti )titre ,
Na e(Print) Current Mailing Address:
Signa re Telephone
S ION 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) Check Number
This Section For Official Use Only
wilding Permit Number: Date Issued:
Signature;
Building Comm iss loner/Inspector of Buildings Date
File#BP-2000-0817
APPLICANT/CONTACT PERSON CDT CONSTRUCTION
ADDRESS/PHONE 158 NORTH MAPLE ST (413)585-8677
PROPERTY LOCATION 17 HANCOCK ST
MAP 32C PARCEL 231 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: PLACE EXISTING ENTRY PORCH/DECKING&REPLACEMENT WINDOWS
New Construction
_ Non Structural interior renovations
Addition to Existin¢
_ Accessory Structure
Building Plans Included•
Owner/Statement or License 003666
3 sets of Plans/Plot Plan
TI-�1 61LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
_!!_Approved as presented/based on information presented.
00a "" __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 Commission Permit from CB Architecture Committee
Signature of Building ficial 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.
17 HANCOCK ST BP-2000-0817
GIs#: COMMONWEALTH OF MASSACHUSETTS
142:Block: 32C-231 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-0817
Project# JS-2000-1542
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: CDT CONSTRUCTION 003666
Lot Size(sq.ft.): 7187.40 Owner: VENNE RICHARD W&
Zoning:URC Applicant. CDT CONSTRUCTION
AT. 17 HANCOCK ST
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677
FLORENCEMA01062 ISSUED ON:3128100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING ENTRY PORCH/DECKING &
REPLACEMENT WINDOWS
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
A
Building 3/28/00 0:00:00 1837 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo