36-018 (2) _J
J
J 1
Vl ti J
4
E
i 1 �
Adw
A 10 IR
El
i
•moo e
13aaEACIIttE[I1E`
e
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMAWT
(Ii censerJpermi flee}
with a principal place of business/residence at:
(phone#)
(street/ci ty/staie/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) (F giration 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) (Insurancc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) Gmsurance Company/Policy Number) (Hxpimtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExT ration Date)
(mach Additioml shoot ifneroczuy to include inform .pertaimng to all ooatraaora)
( ) 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 wElc homcowncn who employ persons to do mxia.,,,,,n wns:ruciioa or rrpair work on a dwmlliag of
not mote than thrto units in which the homoowver r e4des or oa the Vvia is appu exnanj th=to arc no(&ccn=ily eoandard to be
employcra under the womi cz oration Act(GL152,s 1(5)),application by a hotnrowncc far a Gansc o[pefmd may evidence the
les11 etanra of an employe[under the Wockcea C.ompeoution Ad
I und=-eA d that a copy of this etatemmt may bo forwarded to tbo Dcpactmx of lndusfrial Ami&-&Offioc of Imuraaoa for the
coverage verification and that failure to secure covaago under section 25A of MGL 152 can lead to the imposition of criminal Penalties
oomist mg of a fine of up to S1,500.00 emd/or imprison of tip to om year and civil pcm ltia in the form of a Stop Work Order and a
film of S 100.00 a day against tnc.
For d trao only
permit Number
r py Lot#
RMtt re of
3
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
as ere ome mp�ovefimenttCQntracto ",yam Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10,WORKERS':COM PEN SAT16NANSURANCE AFFIDAVIT(M.G L, c. 152, §.25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this a'
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)far
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner
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 ti
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 homeowne
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall
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 t
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for pers
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 l�
fGT10N 5'CTf. O y,RO OAS D 0 K" c eck I lira
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other(} ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement _ Yes No
Plans Attached Roll 0- Sheet 0
f Vew house�and or addition,Ao eXistin ousitEMc"tiple e tl eff-011-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
ECT ON a
OR EB UTHORIZATI0N �TOiBEiCOMPLEATED WHEN
OWNS CNRACTOR APP�lES �ORU�tDING PEaMIT i
as Owner of the subject pro
hereby authorize to
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agen
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
4/��at&reofOwner/Agent Date
r
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 X 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 4 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:
ity of Northampton
uilding Department rb ! v
212 Main Street See Sep rc
Room 100 .
No hampton, MA 01060 e
Y h1PS 13- 87.1240 Fax 413.587-1272 Plot e
APPLICATION TO 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 Fez
Zone � ' ° 2 Oyer a Distrrct ����
Elm St.District CB'D,istnct
S'ECTIO'N 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be ;Official Use,Only
completed by ermit a licant
1. Building , (a) Building Permit Fee
2. Electrical . (b) Estimated Total Costof
` Construction from, 6'
3. Plumbing : Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 5 Check Number
This Section For-Official'-Use,'Onl
'Building Pekrrnit lumber Date Issued r
Stgnature ;
�Buiidi�g Commissioner/Insp"actor of Bulldirlgs Date y
File#BP-2002-0832
APPLICANT/CONTACT PERSON RYAN MARY L TRUSTEE
ADDRESS/PHONE 23 FOREST GLEN DR
PROPERTY LOCATION 23 FOREST GLEN DR
MAP 36 PARCEL 018 001 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
Typeof Construction: RESCREEN CARPORT
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
INF90,RMATION 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 Commission
Signature of Buildin 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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
V:'23 FOREST GLEN DR BP 2002 0832
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV-Block: 36-018 CITY OF NORTHAMPTON
Lot: -001
Permit: B u l l d i niz
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002.0832
Project# JS-2002.1391
Est.Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 14505.48 Owner: RYAN MARY L TRUSTEE
Zoning:URA Applicant: RYAN MARY L TRUSTEE
AT: 23 FOREST GLEN DR
Applicant Address: Phone: Insurance:
23 FOREST GLEN DR (413) 584-2885-0
FLORENCEMA01062 ISSUED ON:413102 0:00:00
TO PERFORM THE FOLLOWING WORK.-RESCREEN CARPORT
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/3/02 0:00:00 1400 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
23 FOREST GLEN DR BP-2002-0$32
czs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-018 CITY OF NORTHAMPTON
Lot:-001
P;rmit: Building
Cate o :Non structural interior renovations B UILDING PERMIT
Permit# BP-2002.0832
Project# JS-2 042.1391
Est.Cost:3500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
!Q t.Class: Contractor: License:
Use Group:
Lot Size(sa ft) 14505.48 Owner• RXAN MARY L TRUSTEE
Zoning:UPLA, Applicant• RYAN MARY L TRUSTEE
AT- 23 FOREST GLEN DR
Applicant Address: Ph one: Insurance:
23 FOREST GLEN DR (413)..584-2885 n
FLORENCEMA01062 ISSUED ON:4131Q2 D:DD:DD
T4 PERFORM THE FOLLOWING WORK.-RESCREEN CARPORT
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: SMgke: Final:Q .- • t'G 'n
THIS PERMIT MAY BE REVOKED BY TWSignature-:,-F NORTH AM ON UPON CATION OF
ANY OF ITS RULES AND REGULATION
Certificate of Occ n
Fee T e: R. t o: _ Date Paid: Check o: Amount:
Building 4/3/02 0:00:00 1400 $25.00
212 Main Street,Phone(413)587-1240,Fax:(4'13)587-1272
Building Commissioner-Anthony Patillo