35-277 FIN
U OCT 1 9
DF7
to
ozr�
C1tAMP�, o(;�
�D4 0 e
� .
a � �7tSaACIIttSCIIS
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE ATTIDAVIT
(licenseeJpermittec)
with a principal place of busmess/residence at.
(phonet#}
(street/city/state/ap)
do hereby certify, under the pains and penalties of pequ-y, 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 0 homeowner cle one) and have hired
the contractors listed below who have the folio e s compensation policies:
S
(Name of ontractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Nagle of Coatractnr) (Tssurance Co:Pany1Poticy Nurr.ber) (Hzpimtion Date)
(Name of Contractor) Unsuunace Company/Policy Number) (Expiration Date)
(auach additional slxct ifnexca:ry to include infoenutice pertaining w all coctractors)
( ) 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 tl a while homeowncra who employ paroas to io in n ac"cc sruc-on C'r repair work on a dwelling of
not more than throe units in which the homoow resides oc oa the pounds zppurtcnanf thtto are no(gcncrz y coesidacd to be
cmployrr9 under the w-kcls ccsrrpc=lion Ad(GL152,-1(5)�application by n homcowncr for a uccrise cc perind may evidence the
legal stnhra of an omployec undartha Worirels Cornpooa&i Ad-
I understand that a copy of thin rtatemmt may ba forwardod to the Department of Industrial Arcidast>'of Goo of Iaarnnoo for tbs
covaage verification and that future to acatre covetngo udder soeiioa 25A of MOL 152 can lead to tha iniposifion of aimiasl penalties
oomisting of a fine of up to S 1,500.00 and/or impris ni of up to ow year and Civil pcmaltia in the form of a Stop Work Onia and a
Eno of 5100.00 a day against tnc.
For dcpaztm zeal u'°only
permit Number
Map# Lot n
Si of Liccn_seclpermitfce e
SECT10 �8��CONSTRUGTION 5ERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�. Nj \ry
QM„ M,ME,. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION JO-.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 affid:
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
r�
The current exemption for"homeowners”was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
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
you hire to perform work for you tinder 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 _
ECTION DESCRIPTI0N0PROPOSEDOR cieckall a ticable
-"-
r;;'�.. ,. .�'� >�?a�13E�_ _-, a nr .._, ,,.,:1 I �_>.<.,."'.0.. ..*wv fis„9>Y'1h F;'...t'�" ....,::'ifs .n•..-
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
_/ Or Doors ❑
Accessory Bldg. ltd' Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: �h
Alteration of existing bedroom Yes_�No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes J/ No
Plans Attached Roll ❑ - Sheet❑
s�a�1fNe�ni �h"�ot 'se��a�nd�orddition to`�-ex�st�n”�g.h��'"usintr;��o�rip'le�etlie,foll.ow�in" :
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
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 OWNERAUTHORIZATION T:0 BE COMPU=TED WHEN
0''NERSAGENT OR'CONTRACTOR APPLIES'FOR UIL nIiVG PERMIT
as Owner of the subject prope
hereby authorize to ac
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 Napy
f0
Signature of Own t 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 36✓ RTC
Frontage
Setbacks Front /� e
Side L: R: L:& R: Aov /
Rear /�� l /O
Building Height
Bldg. Square Footage C76 % c9z2
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 ere any proposed changes to or additions of signs intended for the property ?YES
No�
IF YES, describe size, type and location:
�f I of Northampton
I ing Department
1J Main Street e t
oom 100 e
No tha pton MA 01060 7wn ets o
X587- 240 Fax 413-587.1272 P of/S `e
�Oter Spec►fy.
�g
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This sectibhlto JAM, leted by office
1.1 Property Address: z
t S
c� C n
n i9� (.Ut 5kUn1t
(t ?! ;C2( 1 I I C� C— Map y
a 4 �
Zone Ouerlay�Dtstrtct
O re C 2 M
Elm St. District CBDistrict
SECTION - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�a ry-\ ri�`t' p
Name(Prin �urre t ailing AdZdr�ASf
• Telephone
Signature
2.2 Authorized Agent:
41/uv- C _7`,-� &JJj-cj,(�tcJ T616 re v�c�
Name(Print) Current Mailing Address:
a;-17t zz c cAffi (Vl,� Y z 6;6
cl-
SignAure 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
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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date .
File# BP-2002-0434
APPLICANT/CONTACT PERSON INTRATOR JOANN C& SAMUEL M
ADDRESS/PHONE 84 WOODLAND DR (413)584-2969 Q
PROPERTY LOCATION 84 WOODLAND DR
MAP 35 PARCEL 277 001 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
Typeof Construction:_ERECT 8 X 12 SHED
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 Commissi
/O zs' zce
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-2002-0434
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Bulldlnl7
Category shed BUILDING PERMIT
Permit# BP-2002-0434
Project# JS-2002-0661
Est. Cost: $1560.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 33497.64 Owner: INTRATOR JOANN C& SAMUEL M
Zoning: SR Applicant: INTRATOR JOANN C & SAMUEL M
AT: 84 WOODLAND DR
Applicant Address: Phone: Insurance:
84 WOODLAND DR (413) 584-2969 O
FLORENCEMA01062 ISSUED ON:1012_51W 0:00:00
TO PERFORM THE FOLLOWING WORK:E R E C T 8 X 12 S H E D
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 l0/25/010:00:00 96 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo