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OF BUILDI�,10 ll\:SPECTIONC
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORrCER'S COMPENSATION INSURANCE AFFMAVTr
I '
(licenserJpermi ttee)
with a principal place of business residence av
--- _
(str�U°city/statelrip) ---
do hereby certify, under the pawls and penalties of perjury, that:
( ) I am an employer providing the following worker`s compensation coverage for my
employees working on this job:
(Ina=C_— Company) (Polio 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 Numer) (Expiration Date)
r
(Name of Contractor) (Insuranct: Company/Poky Number) (ExTp mtioa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shed ifncccssary to in(ltudc information pertaining to all ooatradors)
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 wElc homxo-A-n=who cruploy pawns to do m infra.,�com:n:c ioa or repair wurk on a dwelling of
not morn than thrco units in W ich the homoow raid,=or on the grounds appurtenant thxdo arc not ge=es-arty comidcrcd to be
employers uD'cr 6-work&'oempeasatioa Act(GLI52,ts 1(5)),application by a horncowna for a license cc permit may evi&—the
legal datum of an amp Ioyec under the Workcez Compemation A:d-
I undcrstsnd that a copy of this statcmmt may bo forwarded to tho I?cpartascuf of Indw b id A,)6d-ce2 OfEi of In u—for tha
coverage verification and that fa um to ranee co%vnTo under souioa 2 5 A of MG 152 can lad to tho imposition of ai !-I pc W':s
ooasiuing of a fine of up to S 1,300.00 and/or irnpriso=xnt of tip to osx year and ci vil pcnalbcs in the form of a Stop W ork OrdC and a
fine of 5100.00 a day tgninst tr
For dcpntnv —only
permit Number
Iviap t Lot 4
Signature of Licensee/permittm MUe
+ r
SECTION 8--CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9Ftegiter`ediimeImprovement xGontractor �? ��; '� 1��� ` Not Applicable ❑
_ fis
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...... ❑
'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
SECTION 5- DESCRIPTION OF PROPOSED WORK•(check-all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [,'C] Siding [ ] Other [ )
Brief Description of Proposed Work:
Alteration of existing bedroom Yes �" No Adding new bedroom Yes k' No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6aAIf.New„=hous-e°Tandt,o a ddition'to'ezisting dousing, complibte-theJ6116W!'n>r:
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`AG'EN7'O.R 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 p ins and penalties of pyrju�ry.
�Jy Y
7✓ % �
Print Name
Signature of Owner/Agent Date
s
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P z 1e CON Off' yep o S 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 qh ���� b�1 / 6.131
Fee
Frontage
Setbacks Front 0
Side L: R: L: R:
Rear _) O
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 X 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 X
IF YES, describe size, type and location:
f
City of Northampton #�
Building Department
212 Main Street ; ep I
Room 100 a °° !
Northampton, MA 01060
phone 413.587-1240 Fax 413.587-12720 ISitePl 4 �.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
T, is section to be complet' by office
1.1 Property Address: z
d ��r► f�d Map "Lot,Unit :.
rio rent C �R 010 (-c4
Zone ay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Z5a o C:)1 rc)h rj n -HO Cue r/. A 0 RZ El o re)-c e
Name(Print) Current Mailing A dress:
/'/ s ; 411-3 bF6 1613
( � �/4 ?�1 Telephone
Signature
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 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
Building Permit Number: W&) /1 7' Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
File#BP-2002-1174
APPLICANT/CONTACT PERSON CALLAHAN SUSAN
ADDRESS/PHONE 110 OVERLOOK DR (413)586-1613 ()
PROPERTY LOCATION 110 OVERLOOK DR
MAP 29 PARCEL 248 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
1--
Fee Paid
Typeof Construction: RAISE DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildina Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RiMATION 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
2 400 2..1
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.
Ty �
BP-2002.1174
Grs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Deck Addition BUILDING PERMIT
Permit# BP-2002-1174
Project# JS-2002-1882
Est. Cost: $300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor_
Lot Size(sa. ft.): 15028.20 Owner. CALLAHAN SUSAN
Zoning:URA Applicant: CALLAHAN SUSAN
AT. 110 OVERLOOK DR
Applicant Address: Phone: Insurance:
110 OVERLOOK DR (413) 586-1613 (�
FLORENCEMA01062 ISSUED ON.6126102 0:00:00
TO PERFORM THE FOLLOWING WORK:RA SE 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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/26/02 0:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo