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c� DEPARTMENT OP BUILDING INSPECTIONS _
212 Main Street ' Municipal Building
Northampton, 1Jass. 01060
NVOR1CLR'S COMTENSr1TION INSURANCE AEI MAWl'
----------- - -- ----
(li cc-ns�rJr��>
VI-ith a principal place of�lresidcncc at
do hereby certify, under the pains and penalties of perjury, thal
( ) I am an employer providing the followkci s colnocnsao;: cove�gc nor Illy
lm-,
e(uplcvices «ortdng on Ihs job.
(IASUS?�G: Cors=y) (Polio., Nt� r
(--:Pir L o, D2tc)
O I atn a sole proprietor, genera3 contractor or llomeow'ner (ccie one) a_nd have hired
the contractors listed below who h-ave- the ioUo%ving workers ramensation policies:
(Name o.Conf:-nctor) — - Orlsumnc; Colnaan)-PGh -r
-- (Nmc of Coo[Taclor) -- (bvs- ancc. Company/Policy `lii7Crr
. ) (-ExPLr,;uon Date)
(Name of Conuacto;) (Iasuranc; Compan)•/Pouq- (Expl—M000 Date)
(Name of Contractor) (Insurance Comraay/1`06cy Ntm b,cr) (Expn6on Date)
(mach it:ocal c'>:ct if oc'�un to inc!u wforcnLi c�portsjo.ns to all czar cow)
pmprietcr and have no one wol-dng for rile.
am a home owner perforrniug all the work myself.
NOTE:plc Ix e uc tt„•ti{_Je bear-ou -rs uta ,tay P-=Icu w d:,cn ,cam✓:,.^ c Fc�a ork of
sot arat ih a t o 1_.1YJ in wb e the Lxom�,v r,=id�or oo the p ourut. zptx rten r_tbcro—ax e-aUy ars:d c i to be
�yoloycs unG x"�i a a o -liau Act(GL152.n 1(5)�:?puc> bon try a 6 ncoava fm c L a gnu a y c dux trc
Icpl o-t-of e exployx under dio Wok-,,Coa�a ,,e
I understand th.1.copy of thi,ctxl.cmcul m.y bo ro(wnrcted to tbo Dopnrtu,c..,a of In.1.r d�,nadc:2(OIT,—or Lrru«000 for th<
oovense ver-1 icmboa a.M th_t L-iharc to ccxzirc eovcrnsc tad soe on 25A of 1.(GL 152 can lad to the Lmpo5Aion of ertmt¢il penalties
000s»mg of a rtnc of up to S I-SWoo uidtcx en{siionTnc_;�of up to aoc y�r aril pca,t',ia>a t;x form of e Stop Work Ord--d o
run o(-1100.00 A day tPlasl me
Fc ck;a,.tar�l ux oc,ly
P eruli t Number —
�sL� r�te
. i�nalum of LicxnscrJl'cniuttcc
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ET—
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable M--
VT
_g
"d
Company Name Registration Number
Address Expiration Date
Telephone —
SECTION 10-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 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 suvervisor.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 9,5ir--e�w
T •
SECTION 5- DESCRI)IJION QE eROPOSED WORK(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: /0 )(10 sTy/�i4�Ls S ib
Alteration of existing bedroom Yes y�No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes 4----lNo
Plans Attached Roll ❑ - Sheet❑
y ",arm R I et#Ah ejol 1
a. Use of building : One Family Two Family Other 5, � s10ea
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 woos f�/�r�k
i. Is construction within 100 ft. of wetlands? Yes Y No. Is construction within 100 yr. floodplain Yes v°No
j. Depth of basement or cellar floor below finished grade G." ,.)
k. Will building conform to the Building and Zoning regulations? ✓ Yes No .
I. Septic Tank ti's City Sewer Private well L=r City water Supply
SECTION 7a-OWNgR;AUTHORIZATION -TO 6E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES F'Olk BUILDING PERMIT
I, , 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 / �y
Signature of Owner/Agent 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 ^7 3Y 0,
Frontage � /a Of
Setbacks Front
Side L: R: L:c /R: Le O
Rear
Building Height /0 / a 0
Bldg. Square Footage /000 1 p)'P %
Open Space Footage %
(Lot area minus bldg&paved /'70
parking)
#of Parking Spaces
Fill:
volume&Location /�/!f�Y
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW k' 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 i-� 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 ke/
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:
y of Northampton
ild I JUN 72000 8 Ilding Department
12 Main Street
i N s Room 100
NS rhampton, MA 01060
phone 413 587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This section tp'be cc�rr�°p1����I" y offi��a
LG/�
.0111 r7
5- 1144C-5 7— 1204f.5 IF04D
�
Av N�t
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: y--
R,FL) E-Y91 C ' �, �/�l a 4t/,X 7g/V
Name(Print) Current Mailing Address:
-.s-�G
//! Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a),Building Permit Fee
Op:Or
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing d Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4+ 5) p'� O,pO Check Number
This Section For Official Use Only
Building Permit Number: 5P&O91-0 Date Issued; � L�
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2000-1107
APPLICANT/CONTACT PERSON MAILLOUX FREDERICK R&CAROL A
ADDRESS/PHONE 70 TURKEY HILL RD (413)586-4152 Q
PROPERTY LOCATION 25 WEST FARMS RD
MAP 35 PARCEL 270 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid I! cs 9/ —
Typeof Construction: ERECT 10 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing -
Accesso*y Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F 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 Conservation C mmission Permit from CB Architecture Committee
Zoo v
Signature of Building wial 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.
� T
25 WEST FARMS RD BP-2000-1107
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:35-270 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: shed BUILDING PERMIT
Permit# BP-2000-1107
Project# JS-2000-1975
Est.Cost: $2300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 29359.44 Owner: MAILLOUX FREDERICK R&CAROL A
zoning: SR Applicant. MAILLOUX FREDERICK R & CAROL A
AT. 25 WEST FARMS RD
Applicant Address: Phone: Insurance:
70 TURKEY HILL RD (413) 586-4152 (�
FLORENCEMA01062 ISSUED ON.619100 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 10 SHED
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/9/00 0:00:00 3581 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo