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34-022 (2) ,; ► ��`` �',j! ,. �� ` � �.. -v .i � O 4-�11/�AIpT0 � c a � �i1SAC11ttSCIIS m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 y ' WORKER'S COMPENSATION INSURANCE AFMAVIT with a principal place of business/residence at: ✓" � �� /a�,�e�s /��4 �i'%65.� (phonet#) ..aBd�S-lam � (stree-ticity/statelz�p) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: Gasurance Company) (Policy Number) (Expiration Daze) ( ) 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 Coinpany/Poky Number) (Expim6oa Date) (Name of Contractor) (Insurance Company/Pelicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Imzlrance Compaay/Policy Number) (Expii-ation Date) (attach additional slxci ifnccc ly to include kdb nutioo pertaining to all oDd dons) j I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please Ix aware that whAo hco A%nm who cmplay perrons to&maintcaaacr,oxr3t dioo or repair work on a dwelling of not more than throe units in N itcfr the 1]ameowncr rttidcs or ea the grounds appurteranl thcrdo arc W(Ccoa-. ly ea rid-cd to be curploycrs u.ndcr the wmk&s o=ipczuation Act(GL152,=1(5)),application by a homoowna far a Beall"or permit may cvi&rcc the legal etaiun o£aa employer undertho Woricoes compomation Act I unders d that a copy of this ciatcmmt may be forwnrded to the Dcpartmcod of I�duirial Acadm&Offioo of Imuranco For the -Vertge vuificatiou aad that failure to secure ooverago under section 25A of MGL 152 can Icad to the irnpasitiou of criminal pcnakies consisting of n fine of up to S 1,500.00 urs/ot imprisonaxtu of tip to one year and civil pea&W s in the form oC a Stop W orb Order and a Sae of s 100.00 a day tg&inst mer mittee e =Number _ ,�.; SECT I0W,0-.CO"NSTRUCTION SERVICES 8.1 Licensed Construction ervisor: Not Applicable ❑ Name of License Holder : �b'� —7eo?7/f 7 License um er e Jr Addre yy� Expiration Date Signatu Telephone Not Applicable ❑9Ne-HTeYme Ird I c Company NamqJ Registratio N tuber Address Expiration Date Telephbnt9-'5-9d^'" /6? SECTIONi10-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...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwelling-s 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 DESI;RIPTION OF PROPO'SED�WORF�(check�all applicable) �. .. New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other[ ] Brief Description of Proposed Work: �'i✓w-al Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative& Renovating unfinished basement 1Z Yes No Plans Attached Roll ❑ - Sheet❑ 6a ZIfF-NOW h'ou's"es"a'nd or addition to eztstin ho"using,-complete the folloWihk 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 „OWNkk A4GENT OR°.CONTRACTOR:APPLIES FOR„BUILT IHG PERMIT � (, !s�€y� — ✓� ]�€ as Owner of the subject property hereby authorize A /� �� to act on my beh in all matter� ative to work authorized by this building permit application. w f 0 :7 Si ature of Owner Date 9r/ : 1 !'4IF4-e. as Owner/Authorized Agent 1 � hereby declare that the state ents and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed un er the pains and penalties of perjury. &4�5, Q Print Name Signature of ner/A Date 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 Y 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: N r� f Northampton P ing Department G v '--- ---�------� Main Street we i i Room 100 1N r e 1 va 1, V1AR Lv02 Nall pton, MA 01060 phone 41A-587-1240 Fax 413.587-1272 PlotSlte �" 'APPETCATTO T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION;-1 - SITE INFORMATION This section to be completed by offtce 1.1 Property Address: '/ ,�/ Zone - Overlay Dis#rtc# W E�Im St:District CB D.istnct . -. SECTION>2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /� —1 �GSa26' Name int) Current MailinAddr ss: j Signature 2.2 Authorized Agent: Name ri Current Mailing Address: —6—eJ'- 'S/o2 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building Permit Fee 2. Electrical (b) Estimated Total Cost of fQf�O. ©t, Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) / 0 00 Check Number This Section For Official Use.Only Building=Permit;Number: ' T2 Date Issued: Signature: Building Commissioner/Inspector of Buildings. H Date.- I de i+ B13-2002-0757 A1'P(.ICAN'lCON'I'ACT PERSON Craig Marney :ADDRFSSTlK)NE P 0 Box 128 (413) 586-5512 l'ltt)P1 !Zl Y LOCATION 147 TURKEY HILL RD NI:\1' 34_P_\IZC'F-L 0.22 001 ZONE RR '111 IS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE /OMN(i FOIZ\t 1 11.1 'D OUT I ee Paid limidin'-,Permit F Redd_out Fee Pa 1�pc f t:unstructiun; FINISH BASEMENT REC ROOM Ne�� c'unsuuction _. _._.._..------------ Non Structural interior renovations Addition to Existinu lccessory_Structure liuti<i_iny Plans )ncItided: t)wner' Statement or License 057159 sets of Plans Plot Plan LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON !N H0N PRESENTED: \pproved Additional permits required(see below) 111 :kNNING 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 froth 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 Commi 'on 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. °TURKEYEILL RD BP-2002-0757 G1S#: COMMONWEALTH OF MASSACHUSETTS Map:Block:34-022 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2002-0757 Project# JS-2002-1254 Est. Cost: $12000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Craig Marney 057159 Lot Size(sq. ft.): 90735.48 Owner: FOSTER-MOORE PAUL S&LAUREL E Zoning:RR Applicant: Craig Marney AT. 147 TURKEY HILL RD Applicant Address: Phone: Insurance: P 0 Box 128 (413) 586-5512 LEEDSMA01053 ISSUED ON:3111102 0:00:00 TO PERFORM THE FOLLOWING WORK.F I N I S H BASEMENT R EC ROOM 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 3/11/02 0:00:00 3053 $50.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo ____ _ _ _, ---� �----�- t. �_ ..._ ._ . � �'� ;�-� 147 TURKEY HILL RD BP-2002-0757 COMMONWEALTH OF MASSACHUSETTS MVp lock:34-022 CITY OF NORTHAMPTON Lot: Permit: BuiLding Category:Nonstructural interior renovations BUILDING PERMIT Permit# BP-2002.0757 EwieRt i# JS-20.02.1254 Est.Cost:$12000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Cont.Class: Contractor: License: Use Group: Craig Marney 057159 Lot S e(sg.ft.) 90735.4$ Owner: FOSTER-MOORS PAUL &LAUREL E Zoning-uR Ap_ cant: Craig MarneY AT. 147 TURKEY HILL RD Ai7►uticant Address: Phone Insurance; P O Box 128 (413) 586-5512 LEEDSMA01053 ISSILED OM3/11/02 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT REC ROOM 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: 1,c1o.2- 'House# Foundation: Driveway Final: Final: Final: !/ Rough Frame-a( 3 Gas: Fire Department Fireplace/Chimney: Rough; Oil: Insulation: Final: Smoke: Final: &'/< N-/-G ;2. w4w THIS PERMIT MAY REVOKED BY THE CITY OF NORTHAMPTON UPON VICILAM6N OF ANY OF ITS RULES AND REGULATIONS. Certificate of cu an Sig—nature: Fee Tvae - Receipt No: Date Paid: Check Nos'- Amounts Building 3/11/02 0:00:00 3053 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo INN