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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AF+ AVIT
(licenserJpermiUec}
with a principal place of bumness/residence at:
(phone#)
(str=Vcity/st 2dp)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees woriang on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( I am a sole proprietor, general contractor o(Zmeown circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atfach additioml*bed ifneotniry to include infoctnsfion pertaining w all ooatracton)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homcowncra who employ perrom to do ma�fiction cr repair work,on a dwelling of
not aiocc than thtoo units in which the bomoowner r=dcs or on the grounds appurtenant tbacio arc no(malty coasidacd to be
employer,under the wo6-, .erica Ad(GL152,sa 1(5)),application by a homcova"for a U-se or pcfmit may cvidcnoc the
legal rtvtLw of an employer under the Wocico?a Compomatioa Aa-
I undaatand that a copy ofthiu rtatement may bo fbvwarded to tbo Dcpartnxai of lo&id Am&,&Y QII-ioc of imxu oe for tbo
ooveraga vaificatiou aad that failure to soaue coverage under scclioa 25A of MOL 152 can lead to tho imposition of aimin pm&Wcs
coasisti of a fioc of up to 51,500.00 arWor imprisoame xt of up to om yeti and ava penalties in the form of a Stop Work Ord,and a
fim of S 100.00 a day agnimt ma
For d use cely
t Permit Number
Mai Lot#
�Sirn�of Lidnp nee
e
- %
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�iRegistered Horne limprovement-Contractorn, ,� �K�v„ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION e";IRANCE;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 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 buildinp,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.
V--�o meowner Signature Of Y &iAtLA
SECTION'5- DESCRIPTION OF`PROPOSED WORK(check,a l:applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks] Siding [ ] Other
Brief Description of Proposed Work: Q_"o 31ytd_ (;� r t , l z<XuX
Ll
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6:a If New hdouse a°r d or.adtlition to°`existing housing, comp lete'the4611owin�:
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
OWN>fS AGENT OR,CONTRACTOR A,PPL:hES 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 pains and penalties of perjury.
Print Name
r
Date
Signature of Owner/Agent
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 Q. .tcac) /7
Frontage /c��,— /C
Setbacks Front / l
Side L: R: L:0 R: ((J� / 6
Rear (p d /
Building Height CPO
Bldg. Square Footage At
lift. % 0
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:
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DEPT OF BUILDING IN p t
NORT ,Mk(a0� -12 Fax 413-587-1272 PlotfSite puns � � ;
Othei'�SpeC�fi,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
T iis section to 6e completed by office
1.1 Property Address: _ AMINO
Map Lot Unit �`
Zone Overlay
Elm,St`District'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED,AGENT
2.1 Owner of Record:
-1;nh0P 1 >a.PPsle- 6r), f" rte P-z 1,, 01) c
Name(Print) Current Mailing Address:
ATL- /6 � ?
� � .ly, it Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
-T-
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 jo
This Section For Official Use Only
Building Permit Number: 6�! Date Issued:
gnat'Qre
`Yz Byild�ng Comm isslonerllnspector of B,uldirigs, ,,, pate ,
a ,
File#BP-2002-0082
APPLICANT/CONTACT PERSON O'BRIEN MICHAEL&CELESTE
ADDRESS/PHONE 1245 BURTS PIT RD (413)585-1042 O
PROPERTY LOCATION 1245 BURTS PIT RD
MAP 35 PARCEL 083 001 ZONE SR
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: INSTALL 24'ABOVE GROUND POOL WMECK
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 C ission
fly
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.
BP-2002-0082
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Above ground pool BUILDING PERMIT
Permit# BP-2002-0082
Project# JS-2002-0122
Est.Cost: $4700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 17 1 62.64 Owner: O'BRIEN MICHAEL&CELESTE
Zoning: SR Applicant.• O'BRIEN MICHAEL & CELESTE
AT: 1245 BURTS PIT RD
Applicant Address: Phone: Insurance:
1245 BURTS PIT RD (413) 585-1042 ()
FLORENCEMA01062-3628 ISSUED ON:7125101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 24' ABOVE GROUND POOL W/DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
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 si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/25/010:00:00 1406 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo