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29-410 (2) THIS PLAT NOT FOR RECORDING PURPOSES JAN r 7 2002 P.D. 7 y A. 99 �.07— .3, Qb Eli J — ,L -z 8/' soy SANDY H/LL x i ro : .SoVACs oNE Mo,YTCPA&F COAX COM14ON►rvJr4A.7—W 44Wo 7'17'A ' DNS. co. I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES,ANIfPASED ON EXISTING MONUMENTATION,ALL EASEMENTS,ENCROACHMENTS AND BUILDWOS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES.I FURTHER REPORT THAT THE PROPS IS NOT LOCATED IN A FLOOD PRONE AREA AS SHOWN ON FEDERAL INSURANCE MAPS FOR COMMUNrTY NUMBER i DATED: 3" cco NOTE THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES SURVEYOR: NOT CONSTITUTE A PROPERTY SURVEY, MORTGAGE LOAN INSPECTION PLAT �t�iN bf V0RTNA14P r0A1 MASS RIC J.J. o vv Nan Lk"PG4 Sit 7—IM 0*"AY 5, 4,u iS S /,aIZ 13aeos Rcherd J.L SM96,Sr.,Registered Prolesslonal Land Surveyor 110 KJnp StrNt,Noroarnplonn Massachusetts 01060 ZO 39Vd 39aVEVI Z10198SETb ZZ:OT 0002/LZ/EO ��11A1NPJ0 o � - a3f aCl([tS[lta m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT (licenseelpermittee) with a principal place of business/residence at: (phone#) (str'eet/ci ty/stalrla p) do hereby certify, under the pains and penalties of penury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy N (Expiration Date) I am a sole proprietor, general contractor or omeowner ( e one) and have hued the contractors listed below who have the followln s compensation policies: (Name of Contractor) ( =bcr) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sbcc(if noccnuy to inc}udc information pertaining w all 000u'c ra) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whilo homoown=who employ pcnom to do UMUAcu cc�wastn=c a ar rcpau work on a dwetling of not mere than throo units in which the homeowner rraidca or oa the grounds apputtenaoi tbtrcto arc not gcnerally oo=datd to be employ=11 tho worker's oompcns4oa Act(GL152,s3 1(5)},apphicatioo by a homcowoct for a liccase or permit may cvidcnoo the legal etatus of an employer undertho Workoes C.ompematioa Act I undav-snd that a copy of this etatcmeat may bo forwarded to tbo Depwtmcat of Indict id Attidur&Offioo of 1-ursn00 for the coveragc vcrificatioa aad that failure to secure coverago under section 25A of MGL 152 can lead to tbo imposition of aklim,ptxralt:cs ootnisting of a fine of up to$1,500.00 and/or impriso�of up to one year and civil pcniltics in the form of a Stop Work Order and a firm of 5100.00 a day agninsl mc. For drp:ttmc —coly Permit Number Lot# lgnature of a ttee e CbNSRtC IQN,SER1%ICES SEC7b� 8.1 Licensed Construction Supervisor: Not Applicable ❑ I Name of License Holder License Number Address Expiration Date Signature Telephone en n. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-.WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c. 152, §25G(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...... ❑ 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 an cal Zo ' g Laws and State assachus_etts General Laws Annotated. Homeowner Signature r � SE10 No 1�Tt0 OFPROPOSEDWOR Checkah=a licable . x », •Y .0 ".37M 3. *3�, �5,.3n Fi% ,.m^ 74iL' srW °4N New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll❑- Sheet❑ 1f i O. s 1�itl ddit:on.to a wthn, h"o sin corn­UDMAH falYl1001- 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 01NNERS gGEN.T,'OR CONTRpCTOR.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 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. Print e ignature of 0 n r Agent Date i 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 1(21 eTZV Frontage r Setbacks Front 3 j Side L: R: L: /0 �'R: Rear t i f 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: thampton DQu i partment i Street 100 A' JAR ` 7 a , MA 01060 • phone 413-587 124 Fax 413-587-1272 pFPT Or pwl P14)INEPECTIM Sj? APPL CATION TO CON JC 1, ALi ER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION,1 -SITE INFORMATION 1.1 Property Address: s sectio to tiecomp�fi# � '� ce° �--�U L Ce—,yl -,' � � © l O 1 ' Zo s vertay Distrtc# EI'm,St;Distnct` -�€ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: s, I'll o S a ' /o5' .S Q Ad.x 91 u- 2 d p fiRo renee. Name Pint) Cur'$jntt ling �r�ss^ S,-./,72 C 1p Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION'S - 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 >"7 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection (� / 6. Total =(1 + 2 + 3 + 4 + 5) Check Number S v� This Section For Official Use Only Building Permit Number: pt�, Date Issued: x, Signature' 8uiidiniit6rt%missiover/inspect0 r of=Buildirigs _ Date", ' ;.I File#BP-2002-0625 APPLICANT/CONTACT PERSON LUSSIER TIMOTHY S ADDRESS/PHONE 10%SANDY HILL RD (413)584-5432() PROPERTY LOCATION 105 SANDY HILL RD MAP 29 PARCEL 410 001 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 , g5- a T_ypeof Construction: INSTALL 10 X 12 SHED New Construction Non Structural interior renovations Addition to Existingti Accessory Structure Buildin¢Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFATION PRESENTED: L 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 Commission / /0' Z-e 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. BP-2002-0625 GIS#: COMMONWEALTH OF MASSACHUSETTS a :B�ark�29=410 " CITY OF NORTHAMPTON Lot:-001 Permit: Buildin£ Category: shed BUILDING PERMIT Permit# BP-2002-0625 Project# JS-2002-0984 Est. Cost: $1750.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq. ft.): 12414.60 Owner: LUSSIER TIMOTHY S Zoning:URA Applicant: L U S S I E R TIMOTHY S AT. 105 SANDY HILL RD Applicant Address: Phone: Insurance: 105 SANDY HILL RD (413) 584-5432 O FLORENCEMA01062 ISSUED ON.1 110102 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 10 X 12 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: 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 1/10/02 0:00:00 3354 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo