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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE A ' DAVIT
(liceusec/pcmv tree)
with a principal place of busmess/residence at:
--- -- ---- — --(P h o n -
(st��.il'�-itf/statc��p)
do hereby certify, under the pains and penalties of pem' try, that:
( ) I am an employer providing the follotilring worker's compensation coverage for my
employees working on this job:
(I1S M'Ce Company) (folic;Number) V-- v (ExTiration Date)
( ) I and a sole proprietor, general contractor or homecrxoer (circle. one) and have hired
the contractors listed below who have the following worker's ccil;penf,160 policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Hxpi:atioa Date)
(Name of Contractor) (Insurance Coinpany/Poticy Numb-_r) (Expiration Date)
(Name of Contractor) (Inswaac�. Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Numbe-r) (Expiration Date)
(attach a(kdrttoail SiK, if ntccuary to iochL de mformlEon prrtarmmg to all 0001 Ctojs)
O I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:pleas=be aware that while homcowncra who employ to d)maiut�w-asr L c ico cr rryair wwk on a dwelling of
not mote than three units in which the ho--m"mcr resides or oo the ground,app rtes 2trrcto arc oot gcncr2ily coaiidcrcd to be
cmploycrs undcr the wrori cr s am�tioa Act(GLl52,ss 1(5)�applica5on by a home owocr for a Berme cc P-mit may evidc—the
legal statnn of an employee under ttro Wockm s Compensation Ad.
I understand that a copy of this rtatcmcrd may bo fmve"ded to tho Department of I.dusfriel Accident-e Offioo of Inausooc for the
coverage vaificatioa and that failure to secure oovcrngo under section 25A of MGL 152 can lead to the imposition of criminal pusalt:es
ooausting of a fine of up to S1,500.00 andret imprisonmxut of up to one year and civil penalties in dt foam of a Stop Work Order and a
firm of 5100.00 a day against me._—)
For dcgzztu W uto only
Pcrmit Number
Lot#
o LicrnseciPetmi lbte
� ^ w
'
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
rl
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSIURANCE 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.
The current exemption for^'homuo*nem"was extended 0oinclude one(1) or t*o(2)buoUieu
and N allow such homeowner to engage un individual for hire who does not possess ulicense, provided that the owner acts
�as supervisor. CMR 780,
Homeowner: Person(s)who own u parcel o[land on which he/she resides or intends mrexido,ouwbic6derc
is, or is intended to be, a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.
Such"homeowner"shall submit to the Building Official, on a form acceptable to the Building Official,
responsible for all such work performed under the buildiniz permit.
As acting Construction Supervisor your presence on the job site will hc required from time tu time, during and upon
completion of the work for which this permit ioissued.
Also 6u advised that with reference/o Chapter l52(\Yorkom` Compensation) and Chapter l53 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated, you may be liable iorpomou(s)
you hire/o perform work for you under this permit.
The undersigned'^h ^certifies d ' ihiii1y5urcomp|iuocnviUh|hoStutuDui|diugCodo,Ci1yof x Laws Annotated.Ordinances,
rHo meowner Signatur
SECTION 5 DESCRIPTION OF2PROEOSEI)WORK(che ,.,.....
ck all applicable)
_. . _. .-. ... . .. .. .� —... ,. , ...
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding [ ] Other [ ]
Brief Description of Proposed Work: il%e� a'i_NhtG�} C:e=t= Gs trd �2:s� �lftt-t� IV
Alteration of existing bedroom Yes_j� No Adding new bedroom Yes 1✓ No
j Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
self Nevi=hous"exan"d'or-addition to=ezi'sting;t oU§ing; completeAhe.folloWJft: N/A
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'QR;CONTR'ACTOR APPLIES-FOR BUILDING PERMIT
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
l 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 1 Date
f �
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 I`I4< ` I`A
Frontage tai
75
Setbacks Front
Side L: i,)' R: 1V L: R: /
Rear ?
Building Height
Bldg. Square Footage I I '`e %
Open Space Footage %
(Lot area minus bldg&paved 92-
arkin
#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: MIA
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? �I
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:
4
� Northampton
Bw d D,, Department
OCT 1 1 ?Cp1 Main Street ,5 :-
om 100 V,
Wr)dham Aon, MA 01060ets.ci 5 r c aN
DEPTOf BUM P>Q 187.1 40 Fax 413-587-1272 ►ot151te P ans
Uu11bo6s6D
NORTHA N =
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 3. - SITE INFORMATION
This.,section to be completed by office
1.1 Property Address: -� u
L L_l� w!it= �)r2.11�t Map Cots Unit
r � wgt -,
/� M
Elm.St. District" CB Di'stricf"
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
cx Telephone
sign s
2.2 Authorized Agent:
Y �L_I �. Ni v la f"t,L.,
r
N e(Print) Current Mailing Address:
"Ty 'f1I�
Signatu Telephone
SECTION 3'- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted 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) `� .7� 'y Check Number
This c 'on;For Official Use Only
Building Permit Number: /' ' Date Issued':
Signature:
` Date
Building Comrriissionerllnspector of Buildings
File#BP-2002-0399
APPLICANT/CONTACT PERSON MAGGIOLINO LEONARD A&PHYLLIS
ADDRESS/PHONE 36 BEATTIE DR
PROPERTY LOCATION 36 BEATTIE DR
MAP 29 PARCEL 218 001 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
Tyneof Construction: CONSTRUCT 8 X 10 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 ATION 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 Co ission
2091
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.
36 BEATTIE DR BP-2002-0399
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-218 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Deck Addition BUILDING PERMIT
Permit# BP-2002-0399
Proiect# JS-2002-0611
Est. Cost: $700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin: Homeowner as Contractor_
Lot Size(sq. ft.): 13982.76 Owner: MAGGIOLINO LEONARD A&PHYLLIS
Zoning:URA Applicant: MAGGIOLI NO LEONARD A & PHYLLIS
AT: 36 BEATTIE DR
Applicant Address: Phone: Insurance:
36 BEATTIE DR
FLORENCEMA01062 ISSUED ON:10119101 0:00:00
TO PERFORM THE FOLLOWING WORK.-CON STR UCT 8 X 10 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 .. - i f�signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/19/010:00:00 355 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo