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DEPT OF BUILDING INSPECTIONS
NORTHAMPTON,MA 01060
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DEPARTMENT OF BUILDIT G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER`S COMPENSATION INSURANCE t MAVIT
I,
(Iicenser/permittt;e}
with a principal place of business/residence at:
(phone,',')
-- (stir...ticity/statclnp)
do hereby certify, under the pains and penalties of penury, 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)
O 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/Poticy Number) (Expiration Date)
.,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compary/Policy Number) (E>,-piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(amen additional short ifne._YSSary to include information pertaining to all ooaraci r3)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptease be aware that while homeowo=who employ perco•-u to do m31aicrixacc,coin ruction or repair wvrk on n d.vc-EDF of
not more than throo units in wfrch the hotnoowncr resides or oa the gourds zppurtcnant Ihc, t arc not wally ooasidacd to be
cmpto)^as under the worka's ration Act(GL152_zs 1(5)),application by a homcow na for a liccasc oc pcmtit may cvidcaoc the
legal ctataa of an amployec under the Workvet Compomatiou A a-
I understand th,i a copy of this rtztcmmt may bo forwarded to tlro Dq.,tum of I.&L rid Aocid—&OISoo of[—uwoo for the
coverage verification and that failure to sca=coverago tnader soeiioa 25A of MGL 152 can Icad to the in>position of criminal perialtia
oomirtiag of n fine'of up to S 1,500.00 and/or imprisonment of up to one year and civil pcnattia in the form of a Stop Work Orden and a
fum of 5100.00 a day against mG
For dq:atm'�al—oal
permit Number
Mapll_– —Lot
gnaturc of Li crmit#ee e
r
SECTION 8, CONSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor: Not Applicable El
Name of License Holder
� t License Number
c>
Address Expiration Date
Sign atur Telephone
�°i`Registered Nome improvement Cb'ntractorz pP
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affi&
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1O. _ ome Owner xempt><on
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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 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
SECTION-5- DESCRIPTION OF PROPOSEDVORK,jcheck all:applicableY.'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [Vill'
Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a -If°New.house'-`an'd=or addition`to existing Housing, complete oyv
the folling:
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, .OWNER,AUTHORIZATION -TO BE°COMPLETED WHEN
01NNERS'AGENT OR;CONTRACTOR"APPLIES FOR;BUIL'DING PERMIT
I, as Owner of the subject proper
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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
Signature of Owner/Agent Date
1
{
Section 4.
ALL INFORMATION MIDST 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 x Govt/ &D
Frontage
Setbacks Front
Side L: R:
Rear �o
Building Height
Bldg. Square Footage A o %
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 y 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 VZ
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:
F7-
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Z3C !M' epa t .;ent se nl
thampton Status'ofsPerm►t
epartment Cu b CutlDrt n Street SewerlSe ►c �100 Wa�terlWeil�Avatiab►Itty� �� �� �D , MA 01060 Fax 413-587.1272 Plot/Sete Plans '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map—C 3 Lot_ _ - Unit
C) .- —
Zone_ Overlay District
Elm St. District CB District
SECTION 2 -'PROPERTY OWNERS HIP/AUTHORIZED«AGENT
2.1 Owner of Record:
rz,
Name(Print) Current Mailing Address:
r Tee* c� 'Z
Telephone _
Signature -63
2.2 Authorized A_zenV
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS h�
Item Estimated Cost (Dollars)to be Official Use Only
com leted 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: d Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0107
APPLICANT/CONTACT PERSON FOLEY JAMES V&COLLEEN B
ADDRESSIPHONE 10 FOREST GLEN DR (413)584-6370 Q
PROPERTY LOCATION 10 FOREST GLEN DR
MAP 36 PARCEL 003 001 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
bTeof Construction: CONSTRUCT 16 X 8 DETACHED DECK AROUND ABOVE GROUND POOL
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INRMATION PRESENTED:
7Approved 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
Signature of Building icial f 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.
IPOREST GLEN DR BP-2002-0107
GIS#: COMMONWEALTH OF MASSACHUSETTS
..0 io :36-403 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: ALTERATION BUILDING PERMIT
Permit# BP-2002-0107
Project# JS-2002-0152
Est.Cost: $1000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa. ft.): 15333.12 Owner: FOLEY JAMES V&COLLEEN B
zoning: URA Applicant.• FOLEY JAMES V & COLLEEN B
AT. 10 FOREST GLEN DR
Applicant Address: Phone: Insurance:
10 FOREST GLEN DR (413) 584-6370-0
FLORENCEMA01062 ISSUED ON.8131010:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT 16 X 8 DETACHED DECK
AROUND ABOVE GROUND POOL
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 8/3/010:00:00 314 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo