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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Bui1dirnr
Northampton, Mass. 01060
WORI{1 R'S COMPENSATION MURANCE AFFIDAVIT
1, _X14��__ _1!Lt,a n T�_�_-►�� ------------_ _ _ ___
(Ii�nscrJperrni flee j
with a principal place of businessJresidencc at:
✓LD � 1 L�11� 3
do hereby certify under the pains and mialties of pul ury, than.
( ) I aril an employer providing the follo%vint_ "vorr_el's my
employees working on 1111s job-.
(Insuanr Comin}') (Policy Number) ( pintion Date)
O I am a sole proprietor, general con'Tactor of homeowner (circle one) and have hired
the contractors listed below who have the followi .r workers cn:n�.?ensstion policies:
(Naine of Contractor) (Insur-anc-c Coinpany/Pohc-y Number) (E",,ration Date)
(N:)-ne of Contractor) (Insurance Company/Pohc)'NwYb--r) (F`vi� non Date)
-- Q"Tame of Cont actor) --- - (Inszlranc Nlimt-;�,I) - (E1,; lion Date)
(Name of Contractor) (Insurance Comth ny/Pohcy Num r) (Hxi�7-::tion Date)
(atiadt a,M ti cc I c cf if r.ccczur:to inickki,mfxinatioo pcYa inE t:;ell
( � I tuna .�olc proprietor and have no one ,vorking for me.
O I am a home owner performing all the work nlYsclf.
NO hI::plese be aura c ttul�i{ lr n A�nxrs who eIPloy;>zc u
not r occ th n thrco unill in he 1>rxoavcr rciiva cr of L',-Erua.�1_3 z w crW 14 ac o e.-c txt Ica rally ax�!iL�-rcd to b,
calployvs unc;cr the tvod:tis catxcsttion Act(GL152rs 1(5)),ng-iioa6on by a homnowrcr for t I;cc c cK P�^:i:r_y�ei -sxc tlx
legal cta[ue of an employer under trap Wor?tcez Gon4>oo ation .d-
I uzi3c ti d thit a copy of this ctatcn>aii msy bo fomTac cd to tho Dcpn t,, nit of Indium d ArciL- &Oftioo of La:runx for tlm
covczagc verification ctnd that f:ilurc to:mtrc covcrnga under:cCioo 25A of),(M,152 can Ictd to the imposition of r--i-d Penalties
coasutiag of a f of p to S I-500.00 atlN-irn isocmea t o£up to cne)^e r r,:,j ei,,l penalties in tl.c fo m of a St,-,)w` Ord-and a
fittc o Qp y iFrtiin;l fir_
Foe dq%a:t:zrtnl uie only
Permit Nlttntx 1`
I"ot
si to Ltc n_cJPcrnuttcr.
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : JAb r-- f I��YVT 1 A4 n
License Number
0 7/ Z Z \o
Address Expiration Date
Signature Telephone
3 3 -3 t - -Ci
9:'Re i ere Nome`Im v rr7er Contractor „ ;. Not Applicable ❑
Compan_Name Registration Number
/4IfGi+KT—W dU D U/l A!h/ (T J2f .s76l!t I n1 132 9?L/ - --- ----
Address Expiration Date
(0 0-k T_ 12(7)4 f ��Telephoneq 13 '33 /2 S Z U - oS_
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 affid . t
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... G7� )Ern 19 L d
P11: f me Owner-E',empti°on
The current exemption for"homeowners"was extended include Owner-occupied Dwellings of one(1) or two(2) families
and to allow such homeowner to engage an individua or hire who does not possess a license, provided that the owner acts
as supervisor. CMR 7%, Sixth Edition Sectio 108.3.5.1.
Definition of Homeowner erson(s)who own parcel of land on which he/she resides or intends to reside, on which there
is,or is intended to be, a one riyo family dw ling, attached or detached structures accessory to such use anal/or farm
structures. A person who constr is more t an one horne in a two-year period shall not be considered a homeowner.
Such"homeowner" shall submit to th uil in- Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work erforme under the buildiriL, permit.
As acting Construction Supervisor your pre ce on the job site will be required from time to time, during and upon
completion of the work for which this pe nit is issue .
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) 01-the Massachusetts General Laws Annotated, you may be liable for person/-,
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility compliance with the State Building Code, City of
Northampton Ordinances, State and Local "Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature —_ __
'4
Z X 3 6? F(- O
/2 PL t.JVo � C. FCa-t> K
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�i A201 TX-t-- Al p, /v Af /IV 6-
3%2 64-r773: in!�t s ! an �s?q—Z L s
/�L E T/L
SECTION 5-,DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s),�t- Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:�_n I/ywl st.Em1tIV T /b _- 9L"" 14-6-QV"
Alteration of existing bedroom Yes No Adding new bedroom _ Yes _ No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet L.j
6a. if NeW hduse.and or„'addition to existing.housin completethe followin> :
a. Use of buildin : One Family Two Family Other
b. Number of rooms in ch family unit: Number of Bathrooms
c. Is there a garage attached? —
d. Proposed Square footage of new co traction. Dimensions
e. Number of stories?
f. Method of heating?_ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance _— scheck Energy Compliance form attached? __-
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes _ No. Is co truction within 100 yr. fioodplain Yes__ Nc,
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 Prvate well City water Supply_
SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN _F
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize � – _—____— ------ ------
to act on
my behalf, all matters relve to work authorized by this ouild �-._? perr-nit application.
Sign ture of Owner __ Date
VX 09_7>fVtA h — as Ow!</AuL o�Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signe under the pains and penalties of perjury.
rT
Print Name J
Signature of Own t Date
t
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: _
D. Are there any proposed changes to or additions of signs intended for the property ?YES —
No
IF-YES, describe size, type and location:_
City of Northampton SatusofPerrxtt#
Building Department Curb Gut/D `ve a e.• "' ;�,�k�
212 Main Street S6,wer/'S'P Ic
Room 100 WatWw"@ix"Val
Northampton, MA 01060 Two Set ofStY
phone 413-587-1240 Fax 413.587 1272 P,Iot/Site Pian
Other Speci Ij�P � t , `
------ ------ --
--- — —
APPLICATION 70 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be-completed by office
1.1 Property Address:
�3 w0 0D Of^4 .Dru v�
Map Lot Unit
Zone— Overlay District
Elrn St. District__ C13 District ____-
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2_1.Owne_r of Record:
A-anL6 c - K1-i�c E_Ly-%/CI+ -- ------ — - - - -
ar n IS ddress.
`igr�,a-ire
2.2 Authorized_Agent_
114.D C,. m o n-T A4 k-r,
�igrat.,r T�:i ,ne
SECTION 3 _ESTIMATED CONSTRUCTION COSTS
,�;r;� Estir anted Comet("��I'as` Official Use Only
'. cornr)leted
1;Iding Permit t=ee
000
ed Total Cost of
31 Building uction from (5�i
;it�i r, t P ermit Fee
5. Fire Prot- t!on
I I
6. total = (i + 2 + 3 + 4 t 1 Z 0c) < hecn NumlDer
This Section For Official Use Only
w� ---- — ----
Building Permit Number- v7—_�<�3—_—__—.___ Cate issued:
I Signature: —
Building Co'rnmissioner/inspector of E3uilc rs mate
File#BP-2004-0503
APPLICANT/CONTACT PERSON JADE MORTIMER
ADDRESS/PHONE 28 FORGET RD (413)339-4298
PROPERTY LOCATION 93 WOODLAND DR
MAP 35 PARCEL 294 001 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: FINISH BASEMENT INTO PLAYROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 071226
3 sets of Plans/Plot Plan
THE FgELOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,QRMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With 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 ssion
a i 1200—
Signature of Building O icial 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.
93 WOODLAND DR1 BP-2004-0503
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-294 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category BUILDING PERMIT
Permit# BP-2004-0503
Project# 35-2004-0714
Est. Cost: $6200.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grout: JADE MORTIMER 071226
Lot Size(sq. ft.): 32713.56 Owner: CIRINCIONE KIRSTEN&JANE LYNCH
Zoning: SR Applicant: JADE MORTIMER
AT: 93 WOODLAND DR
Applicant Address: Phone: Insurance:
28 FORGET RD (413) 339-4298
HAWLEYMA132974 ISSUED ON:10129103 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT INTO PLAYROOM
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:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/29/03 0:00:00 500 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo