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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
(li censer/permi ttee)
with a principal place of business/residence at:
(phone#)
(strcei/ci ty/stafrJa 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:
ansu-ranee Company) (Policy Number) (Expiration Date)
( ) 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) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Hxpimbon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additica2i&Scct ifn6ccu to include infixmatioa pacai to&B omtract.ors)
( ) 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 while homc-,owo=who emplay,pertous to do mmiot ,nc,!,coastvetioo or rtpair work on a dwelling of
not more than throe und'to which the homeowner r md,=a on tl t ground,appurtenant tha do arc ooe many eoasidatd to be
employes it the wockces mmpeusatica Act(GL152.-s 1(5)},application by a homcowncr for a liccase cc pclma may cvidcnoc the
legal ststua of an employer under the Workeet compdmation Act_
I understand that a copy of thin rulcme at may be forwurdad to the Deportmcrd of T-L, i J Acadc,1s'Offioo of l=ursnco for the
coverage verification and that failure to secure coveango trader s4c;uca 25A of MGL 152 can Icad to the impos ioa of critniaal pcn116es
eo¢sistiag of a fine of up to S 1,500.00 and/oc irn isotmsc�of tip to one year and civil pcwltia in t6c form of a stop Work Otdcz and a
film of 5100.00 a day agniml tae..
For dep�uao only
permit Number
C'-
1&0 Lot'#
:,r� Stgnawre of LiccnseelPermittee 2
E�Tb $� 'CONSIRUCTIONSE3RVICES ri
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
2e� e .`.°. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone_
SECTION 10-,.WORKERS' COMPENSATION 1 NSURANCE AFFIDAVIT(M.GL. c. 152, § 25C(6)),
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidE
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
' O :N1•
� w.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familic
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(.
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 `s ` "`
s
X.
SECTIOI DES:CRIPTf'. O ROPO�SED3oWORK 1,C C Ilia IiQatile
PC
,a<�.wv�snaxa•.. nn«a.yam A�.�..ar.. smaw ..a.,:�.me„n, >e.�rr 'r«r�>;a�...,-.
New House ❑ Addition ❑ Replacement Windows Alteration(s�. Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding( ] Other [ ]
Brief Description of Proposed Work: 1 `X ) be-�.L,4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
( 1fiMe o sera`rid Wdddition t�xistingWeeti0 sing 'cotri'p1e"teethe fol•Iou Jn :
a. Use of building : One Family Two Family _Other
b. Number of rooms in each family unit: Number of Bathrooms �Z
c. Is there a garage attached?
d. Proposed Square footage of new construction. 1✓ �! Dimensions
I
e. Number of stories? ter .-_ S7 >C
f. Method of heating? S "� 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
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
7# ION 7a; OWNER AUTHORCZATION TO BE COMPLETED .WHEN
0 YVNER5 AGEI OR CON'CRACTOIZ APPLIES FQR BUi1.nING PERMIT
as Owner of the subject proper
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
/1
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 p ins and penalties of p rjur .
Print Name
Signature of Owner/Agent Date !!!
I ,
c
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:_
• ry
�( of Northampton
I ing Department
2 Main Street
Rr F; A 2 7 2CG1 Room 100
orth mpton, MA 01060 o
'DEPT Of BUILDIN@ 9"1 -58 -1240 Fax 413-587-1272 0 1,,tt a
NORINAMP?ON,MA 01060 ( h e
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This sectio Ito lie completedliy office f
1.1 Property Address:
�� � ✓ .Map }� � � Lot ��"` � ��LJn�t����
s a# a c
/ ZoneO�erlay Distrt t�
Elm St.,Distric(' CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTI'MATED 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
1 , Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) cc ^- Check Number �p'� ✓
This Section For Official Use Only
Euilding Permif Number. ''Qa'�c��� Date Issued:
S�gnaturd
',_. ' Bu%ldirag'Commissioner/J,nspector,of B�rlld��gs Date.,. ,.
File#BP-2002-0220
APPLICANT/CPNTACT PERSON NASH PHILLIP A&MARGARET J
ADDRESS/PHONE 31 GOLDEN DR 5 5?
PROPERTY LOCATION 31 GOLDEN DR
MAP 29 PARCEL 421 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out It OV
Fee Paid
Atw-
TMeof Construction: FINISH BASEMENT
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
INFOy�1VIATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§_
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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
_g- 7- vi
Signature of Buildingd2ficial 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.
F.
BP-2002-0220
GIs#: COMMONWEALTH OF MASSACHUSETTS
r' k-2 '42 ` CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0220
Project# JS-2002-0342
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 13721 .40 Owner: NASH PHILLIP A&MARGARET J
Zoning:U Applicant. NASH PHILLIP A & MARGARET J
AT. 31 GOLDEN DR
Applicant Address: Phone: Insurance:
31 GOLDEN DR (413) 585-5796 ()
FLORENCEMA01062 ISSUED ON:81291010:00:00
TO PERFORM THE FOLLOWING WORK:F N I S BASEM ENT
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:
Building 8/29/010:00:00 1625 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo