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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOM,{ER'S COMPENSATION INSURANCE Arl MAVIT
(li�rLSer�permi ctec>
with a principal place of business/residence at:
1p s(L Q�0(37� (phone#) 25�• ��
( city/stalt' zip)
do hereby certify, under the pains and penalties o6cou y, that:
i
( ) I am an employer providing the foIloWlg wo!Fker's compensation coverage for my
employees wor4dng on this job:
(Insurance 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 Comparry,Tolicy Number) (Expim6oa Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Compaty/Poky Number) (Eaxpiradon Date)
(Name of Contractor) (Insurance Compamy/Policy Number) (Expiration Date)
(attach "octal lbccd ifn ui cc to mchidc iaformatioa pertaining to aL'ooasaUOrs)
( I am a sole proprietor and have no one working for me. UL � p11�1SU4 S
I am a home owner performing all the work myself. 1i N44 Wdus2S ��`P
( ) P g Y (i�A� %'Qvkv%�-
<pbL'1C r( t�°�u' Anfl �
NOTE:please be aware tha wfrilo homcouvcta who employ pczom to do ma mum,�constj=oa or repairµark on a dwelling of
not mcce than thrbo units in wfndr the homeowner rides or oa the grouaiis zppur�thcx o ate oo(gcacrrally 000sidacd to be
employers urkicr the worker's compcasation Act(GL152-s 1(5)�application by a homoow=for a Uccccase cc permit may evidcn c the
lggd antra of an employer under tan Worker's Compomation AIL
I understand thst a copy of this rtacmcat nuy 1w focwu dad to the Detxirt ax of Indu:h id Ardd=&Offioo of Imsuxnce for the
eovaxga vaific stioa and that failure to scwre coverng under soction 25A of MGL 152 can lead to the imposi ion of criminal penalties
of a fine of up to S1,500.00 and/or irnrrisossnxvt of up to one ymr and civil penalties in the form of a Stop Work Ord=and a
of S 100.00 i day sgkinst try
Foe dep-tnserfal use oaly
Permit Number
W14 Lot n
C t#ce
Si of Li e
Y
SECTI'O'N'8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1,, ^^, Not Applicable ❑
Name of License Holder :_1\�����►�"` �1`�I � A-rD 'Z)
License Number
1 �• Q_f•,� di . ZZ.02
Ad r s Expiration Date
Si nat Telephone
t ,�, °Ya.-r .. -5�. ..,.e e-. 'm a rtk4 `k l.f 5kn-• I t°'E
d�Horne�im r vement�Con racto'r Not Applicable ❑
CoT �'t�ts 10 S
Company Name Registration Number
�5� O DC�• 2�•o�
A r ss Q Expiration Date
TelephoneA� 1 U�
ECf10N11 - WORKE ' COMPENSATION INSURANCE AFFIDAVIT(M.G L. c. 152, § 25C(6))
Wor ompensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidE
will result in the denial of the issuance f the building permit.
Signed Affidavit Attached Yes....... No...... ❑
O
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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
SECTION 5 "DESCRIPTION OF°PROPOSED--YVORKScheckrall apalicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ]
Brief Description of Proposed Work:��lN�f'�U�1C'� 15`�I��OQGb� 4 WL t-MA b'60 -
Alteration of existing bedroom Yes No Adding new bedroom Yes ,/N 0
Attached Narrative❑ Renovating unfinished basement Yes �No
Plans Attached Roll ❑ . Sheet
Sa If New..h°ouse'and or:addition°to°ezistin` houSin C0Mp1bte the fd116Wink:
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. 2 U _ Dimensions �5��(0
e. Number of stories? t
f. Method of heating? - Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of con truction
i. Is constru ion within 100 ft. of wetlands? Yes �o. Is construction within 100 yr. floodplain Yes
j. Depth of asement or cellar floor below finished grade
k. Will buil ing conform to the Building and Zoning regulations? _ Yes No .
I. Septic ank City Sewer Private well City water Supply
SECTION NER.ALITHORIZATION =TO;BE COMPLETED WHEN
OYYNERS' , OR CONTRACTOR',`APPLIES-FOR;-BUILDING PERMIT
as Owner of the subject proper
V V hereby a thor z to ac'.
my behalf,, i al tte rel ' e o utho ' ed y this building permit application./-�'\ ._ — -'?-
Signature Owner date
E mw5y`j Of S C'CU� as Owner(Authorized Agen
hereby declare that the statemen s and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the ins and penalties of perjury.
NPrinteAgen ate
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 `CJT) l lt S�
Side L: R:-t*� L: �R: V`
070
Rear 7W
I0
Building Height `30
F
Bldg. Square Footage OD %
Open Space Footage %
(Lot area minus bldg&paved q k Qil
parking) V C> l
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Fin ding ever been issued for/on the site?
NO DON'T KNOW V/ 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 ere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
rthampton Status of Permit ,
Buil i epartment Curb$Cut/DnvewayPermlt ��
4 ,
i � 2 i n Street SewerlSepticA
}J A� Roo 100 VVaterlWell Availatiillty
pt n, MA 01060 Two Sets of Structural
pE�Of�� 1 124 Fax 413.587-1272 Plot' to
0
Other Specify
F
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
634M%N� U� 5T2H LTI.)tL,� b�,u�u M (
SECTION 1 - SITE INFORMATION. H'�/LS r� uAA UIan-
This section to be.completed by office
1.1 Property Address:
M Lot Unit
Z Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT°
2.10 ner of Record:
N m P in ) Current Mailin Address,: pZ
_ Telephone
�/'_ Si ature —_
2.2 Authorized Agent:
P int Current Mail�niil g Ad less:
2� Wsa'
ign r Telephone
ECTION - ESTIMA413 CONSTRUCTION COSTS
It 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) 5 Q Check Number
This Section For Official Use Only
Building'`Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0137
APPLICANT/CONTACT PERSON ELEMENTS OF STRUCTURE
ADDRESS/PHONE 664 MAIN ST (412)256-8053
PROPERTY LOCATION 242 SYLVESTER RD
MAP 28 PARCEL 066 001 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 77 1aT5
Typeof Construction: CONSTRUCT 16 X 15 PORCH& 10 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 054510
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFjfSRMATION 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
Signature of Building OffVial 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.
42 SYLVEST> R RD b BP-2002-0137
-
GIS#: COMMONWEALTH OF MASSACHUSETTS
slack:
2 8-066 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: ADDITION BUILDING PERMIT
Permit# BP-2002-0137
Proiect# JS-2002-0215
Est.Cost: $24250.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ELEMENTS OF STRUCTURE 054510
Lot Size(sq. ft.): 935668.80 Owner: LEVINE CINDY B
Zoning:URA Applicant: ELEMENTS OF STRUCTURE
AT: 242 SYLVESTER RD
Applicant Address: Phone: Insurance:
664 MAIN ST (412) 256-8053
AM H E R STM A01002 ISSUED ON.-8110101 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 16 X 15 PORCH & 10 X 12 DECK
RPOST THIS CARD SO IT IS VISIBLE FRO M THE STREET q OK " ` �<
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/10/010:00:00 1896 $125.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo