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35-115 (3) I i',. _ `I (tt '� l�' �� -� �� �`� I V. �. 'ti' 1 III�II� 1`� �� �'I ���r ��+ I' t i I� �; ��� ,! i , ii �,� 77 pe 2 6 2001 WILDING INSPECTIONS ENO PTON,NIA 01060 AVIE, '7/q C4 0/�0 G or Y F5 zo DH -TOI �7- -rc) IAI :, ,,. �!I 'II ii �'�,f f :. i� �I� i it !lid -- j F,Rjut"', 2 6 2Q0) pFpT OF Il01N ,INSPECTIONS NORT, PION,MA 01060 i 0 m ii P TF I"-- 'i t.� ._.... (�E�,l 0/2 �OOa �x Of Wart jamptian `,� 6 ,�lasaachasrtta' m DEPARTMENT OF BUILDr NG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licenseepermittee) with a principal place of business/residence at: (phone#) (st=t/city/statrhsp) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working 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 Company/Policy Number) (Expiration Date) +f (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach addidocW sheet if necemmy to include infonnation pertaining to all coatactora) riI 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 homeow om who employ pasoas to do majdenzace,coach uctioa or repair work on a dwelling of not note thaw throe units is which the homeowner resides or an the grounds appurtenant,thereto ate not Coxtslty comidaed to be employers under the worker's oowpc=siioa Act(GL152,s1(5)�application by a homeowner fora 6ccwe or permitmay evide000 the legalctabs of anamployerunder the Worke r'eCompemdionAct I undemund that a oopy of this mtemsat may be fmwardad to the Depertc�of Indsutrial Aocidmts Off oc of Irssrusooe for the coverage verification wad that failure to seatre coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties oomLtemg of a fine of up to$1,500.00 andfor impr6ormxs1 of up to one year and civil penalties in the form of a Stop Work Order and a fins of S 100.00 a day against me. g«dal uao only permit Number Map#--Lot# Signature of Licensee/Permittee • vo E 8-CONSTRUCTION''SERVICES .1 Licensed Construction Su ervi or: Not Applicable ❑ If�f� �^.,_,,, aa) � Name of License Holder � �� �. Ric �,�,�h! License Number s w cut,�cL -3 I-e-7 10,z- Address Expiration Date Signature Telephone fFE ", spyfF ..'....,� a .x " Not Applicable ❑ c Company Name Registration Nu ber Address Expiration ate ucQ, Telephone SECTION 10-WORKERS'°OOMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§250(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. 'gned 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 TI I cable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑G xo�6 N w S' ns [ ] / C Dec ks Siding[ ] Other [ ] Brief Descript'on of Proposed Work: , Alteration of existin bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet k 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 SECTION 74-OWN.ER'AUTHORIZATION,-TO 13E COMPLETED.WHEN � Yf1N)*RS.ACa1<NT DR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize �� to act on my behalf, in all ter rela e to work�urized by this building permit applicatio Signature of Own r 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. �Kignecl under the pai an penaltipas of perjury Print Name O Signature of Owner/Agent Date # ^V 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 �Cp� ( CCG — dj Frontage f3c> Setbacks Front 30 Side L: _R: R: _ 6 G Rear u q l 3 �3 O Building Height V l fFi Bldg. Square Footage —y % p q 1 (® Open Space Footage C' (Lot area minus bldg&paved 1 -\ Z�Cj 3 parking) #of Parking Spaces 2 Z 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 k IF YES, describe size, type and location: D. Chere any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: LS lul E t! v orthampton ® Bu i Departments JUL 2 6 2001 ain Street Ro m 100 LNS amp on, MA 01060 NORTt OEORT i}�1�•4 7-1 40 Fax 413-587-1272 +l�'►'on APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT,[ON 1-SITE INFORMATION 1.1 Property Address: This f /, / �15Cti`1 1�� F� tl � lap {�• � A a �� �� ICI���r�� i'ct `�' SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ow of ecord: W -, �v � k 'oz_ '-&"w � �- ► CQ me(Print) Current Mailing A drres�� t., • Telephone Signature 2.2 Authawdzed A ent: la k V4 Name(Print) Current Mailing Address: 5_aLk -- 33 � Signature Telephone SECTION 3-ESTIMATEDGbNSTRUCTION COSTS' Item Estimated Cost(Dollars)to be Official Use Only; c pleted by ermit applicant 1. Building CO (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) G" 00 Check Number is Section Fpf Official Use Only ulldng Permit plumber: ,,�.. Date Issued: Signature: Building Comm issionerAnspector of Buildings Crate File#BP-2002-0105 APPLICANT/CONTACT PERSON Paul McCutcheon ADDRESS/PHONE 87 Chestnut St (413)584-3352 PROPERTY LOCATION 77 FOREST GLEN DR MAP 29 PARCEL 115 001 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 T_yneof Construction• CONSTRU T 16 X 20 DECK W/ 10 X 10 LOWER DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 062544 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN7F MATION 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 8'•;2.0 4SignatuAre� o 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. 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I r _ 1 K �1 , �f 77 FOREST GLEN DR -2002-0105 GIs#: COidMONWEALTH OF MASSACHUSETTS Map:Block:29- 115 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Deck Addition BUILDING PERMIT Permit# BP-2002-0105 Project# JS-2002-0149 Est.Cost: $3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Paul McCutcheon 062544 Lot Siz sg.ft.): 13982.76 Owner: MCCUTCHEON PAUL C&MARCHELE Zoning:URA Applicant: Paul McCutcheon -_ AT: 77 FOREST GLEN DR Applicant Address: Phone: Insurance: 87 Chestnut St (413) 584-3352 FLORENCEMA01062 ISSUED ON:8131010:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X 20 DECK W/ 10 X 10 LOWER 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: LOWLC I ill Final: Final: R � K !© - Rough Frame: w Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:OK P-7 THIS PERMIT MAY BE REVOKED BY THE CITY OF ORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/3/010:00:00 4964 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo