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35-018 (2) is D VAR 7 ZMl �E of BUILD NG NORIHAMPTON,MAP01060NS v �-V 0711+11 l�10(7' (119(y yi f l Y 04�11P20 Z _ $ 6 �asaacllnsrtta` DEPARTMENT OF BUILDDIG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. D1060 WORKER'S COMPENSATION INSURANCE AFFIPAVTT Cn f(? C . (licenserJpermittee) ; with a principal place of business/residence at: d� (phone#) v ( ty/sta&nP) do hereby certify, under the pains and penalties of ped-ury, that: 5. O I am an employer providing the following worker's compensation coverage for my employees working on this job: f (mince Company) (Policy Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired z 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/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (auach additional shod ifneocz a to me}ude information pertaining to all cootrado ) O I am a sole proprietor and have no one working for me. X,4'I am a home owner performing all the work myself. �NOTE:Please be aware that whUo homc-m rs who employ persons to do maintenance,eonsuvctioa or rcpas work on a dwelling of not more than three units is which the homeowner resides or ou the groauds gVurteuaod thereto arc not gmc rally ooandered to be employers under the worker's compcasatioa Act(GL152,ss 1(5)),application lry a homeowner for a license or permit may evideaoc rho legal stirrer of an employer under the Wodcoet Compematioa Act_ I understand that a copy of thin statement may be forwarded to the Depuftwot of lo&L*ial Axidoo&Offioo of Iasursnoe for the coverage verification aid that failure to—cowmp under soctioa 25A of MGL 152 can lead to the imposition of—and penalties coosisti ng of a fine of up to S1,500.00 and/or of up to one year and civil penalties is the form of a Stop Work.Order and a fino of 510100 a day against me For dgmtm=w uao arty k) Permit Number gyp# _Lot# Signature aLicensee/Permittee —4 ..-G-.alas.. _:.:sShc:• LSECTION 8,:"111 CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone Not Applicable ❑ g Company Name Registration Number Address Expiration Date Telephone SEPTIOR,10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§215C(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. ignecl Affidavit Attached Yes....... No...... ❑ 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 D OP c . a New House ❑ Addition ❑ Replacement Windows Alteration(s Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Cher [ ] rief Description of Proposed Work: MdO l Y u 4'U> �✓� 1 Alteration of existing bedroom /Yes No Adding new bedroom Yes io�No Attached Narrative❑ Renovating unfinished basement Yes _J "No Plans Attached Roll ❑ - Sheet❑ 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? 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 S CTIS 7a-#�VV�ER AUTHOR,40110 T©'�E COMPLETED ED WHEN .�!1 OwN 'A C ©R CO TRACTt?R A pI:IES ep, BUt�:DrNG 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 I, N to C 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. igned under the pains and penalties of perjury. Ch Print Na e ignature of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION \,V 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: thampton 1 partment 21 i Street 7 2001 100 Northa pto , MA 01060 oE�-- i L tN I S i I g 24 Fax 413-587-1272 NORTHAMPTON,MA 01060 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SETI1N 3 S17E INFORMATION k 1.1 Property Address: Al Ap SE TiON'2-PROP)E TI(OWN,ERSHIPIAUTHORIZED AGENT _ 2.1 Owner of Record: —"--^ - -- -------- Zip Name(Print Cu rr iii t Mailin Teldpp ne^ Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone S CTIO ' ESTIMATEQ'CON5TRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use',Oniv. completed by ermit applicant Building ®� (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost.of �q(�a Construction from 6 3. Plumbing BuildingPermit Fee 4. Mechanical (HVAC) ire Protection 6. Total =0 + 2 + 3 +4 +5) Check,Number T his Section For Official Use Only' Buifdttg�lermi't Number. Date Issued, Signbture 3 fig'Corn ildi 'mis of r/inspector of guildings Date File#BP-2001-0717 APPLICANT/CONTACT PERSON CHAN CHIO ADDRESS/PHONE 48 CHARON TERR (413)538-5796 Q PROPERTY LOCATION 132 WEST FARMS RD MAP 35 PARCEL 018 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid TWeof Construction: CONSTRUCT PARTITION WALL TO CREATE HALL SHEETROCK&INSULATE BEDROOMS New Construction Non Structural interior renovations Addition to Existin¢ Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Conservatio„K fr mmission Permit from CB Arch*tecture Committee Signature of Building Official Da e 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. ,:- - __�� �._ � , . u ,�_����_ . � , - .. . 132 WEST FARMS RD BP-2001-0717 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-018 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0717 Project# JS-2001-1139 Est.Cost: $5900.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sq. ft.): 23348.16 Owner. CHAN CHID Toning:_SR Applicant: CHAN CHIO AT. 132 WEST FARMS RD Applicant Address: Phone: Insurance: 48 CHARON TERR (413) 538-5796 (� SOUTH HADLEYMA01075 ISSUED ON:319101 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT PARTITION WALL TO CREATE HALL, SHEETROCK & INSULATE BEDROOMS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wining �_/�'D-.P.W. Inspector of Buildings Underground: Service: vi/`�'/U/.�'�l Meter: � r Footings: Rough/A %Z ��� Rough:,�51/y,/U/ House# Foundation: Final: �p Final: �y �/� (� Frame:h Rou g Gas Fire Department Fireplace/Chimney: Rough: Insuiatiowd k -3 Final: Smoke: Final: A .[s /7- /o//112-12001 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy.�-155�;' si nature:111 Fee Type: Receipt No: Date Paid: Check No: Amount: Building 3/9/010:00:00 973 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo