35-279 (3) R 0 v R
JAN 8 -Dt
DEPT,OF BUILDING IN NS
MA 01060
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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CONTENSATTON INSURANCE AFFIDAVIT
(IicenseeJpermittee)
with a principal place of business/residence at:
9�6 WIbuLANV VgZiK 40AEP&E MA- NO-- (phone#) ql� 5bs y1_2.9
(streef/ci ty/stale/a P)
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 worming 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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poficy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) , (Expiration Date)
(attach addidoml Shea if necessuy to include infocmaaon pertaining to all ooakadon)
( ) 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 whilo homeowners who employ persons to do ataint nan e,c=studionor repair work on a dwelling of
not more than throe units is which the homeowner resides or oa tho grounds appurtenant thereto arc not generally oocudered to be
employers under the worker's comp=s4ca Ad(GL152,ss 1(5)),application by a homeowner for a licease or permit may evidenoe the
legal status of an employer under the Worker's compomation Act.
I understand that a copy of this statement may be forwarded to the DepaAmwd of In hL ftial Ac6den&Oihoo of Innruaaoe for the
covaage verification and that failure to secure coverage under section 25A of MOL 152 can kad to the imP�on of criminal penalties
oomistmg of a fine of up to S1,500.00 and/or imprison of up to one ytar and civil pemrlties in the form of a stop Work order and a
firm ofS100.00 a day againsttnc
For sl use Daly
�'t Number Lot#
P#
�1
Signat=of Licensee/Permittee V Bare
�ECTIIDN 8-CONSTRi]C710N SEF2VICES
1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
l Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1Q-WORKERS' OMPEN51 Tt0 1 INS t ANCE kFF AVIT(M.G L.c. 152, 200
(P))
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.
igned 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 responsibi'ty for compliance with the State Building Code,City of
Northampton Ordinances,State and ocal Zonm aws a St of Massachusetts General Laws Annotated.
omeowner Signature
EscRlPr o oP„'
3,
1'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other N.
Brief Description of Proposed Work: E i-Cr it_A L AND DA W4k
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement 1�- Yes 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 .
1. Septic Tank City Sewer Private well City water Supply
S CtidN 7a ,OWNERAUTHORIZATI N TtJ C4IVIPI:E7Ea WHEN
,,iCtWiS AGI�T OR CQNTRIfN APPLN)�SQ#, lltlt?1NG PNtfT
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
?e l d- 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.
Print mZgA
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
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:
1 D. Are there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
2 orthampton
� [s I
,M Bui Department
JAN 8 -V( 2 ain Street
rn 100
pf Ito��9UI�lD�I ►�S mpton, MA 01060
- -°° e 'I' 87--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: 3 � z
L
"$EP"FION 2-"PROPERTY OWNERSHIPIAUTHORt2
�'CJ .3L
2.1 Owner of Record:
QiEiEA A. + 1E I;-1J B
ame(P ' ) A,- C ed ��3�/x/
Signature
2.2 Authorized Agent:
SMu�
Name(Print) Current Mailing Address:
Signature Telephone
EtTIO . .
I STRUCTION"CO
ESTIMATEDCO ST
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant.
1. Building (a)"Rililding Permit Fee
I Soo s
2. Electrical 5Dn i (b) Estimated Total"Cost of
Construction frorn I;i.
3. Plumbing
Bull 'Permit Fes.
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Z DOJ.,
Check Number
is Section For dfficial',Use Ohl
Building Permit Number: + " Date Issued:
Signature: ', „
Building CommissionerllnspectaY_ofB l,dings " Date.
� f
File#BP-2001-0623
APPLICANT/CONTACT PERSON BOND PETER&JEAN
ADDRESS/PHONE 98 WOODLAND DR (413)584-9229 Q
PROPERTY LOCATION 98 WOODLAND DR
MAP 35 PARCEL 279 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: FINISH 12 X 36 BASEMENT AREA
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 PLLOWING 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 Commission Permit from CB Architecture Committee
Z-
Signature of Building fficial 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.
98 WOODLAND DR BP-2001-0623
G1S#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block:35-279 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category'Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0623
Project# JS-2001-1107
Est.Cost:$2000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot size sg. ft.): 35283.60 Owner: BOND PETER&JEAN
Zoning: SR Applicant.• BOND PETER & JEAN
AT. 98 WOODLAND DR
Applicant Address: Phone: Insurance:
98 WOODLAND DR (413) 584-9229 ()
FLORENCEMA01062 ISSUED ON:1 19101 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH 12 X 36 BASEMENT AREA
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 Siunature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/9/010:00:00 106 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo