36-053 (2) O
I
�&� ; MAY - 8 2002
Ica ' �
Q-.S tiAM Pip
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�iIIE ACIInSCIIII
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE AFFIDAM
Ir _
(litxnserJpermi��ee}
with a principal place of business/residence at:
(phone#)
(St=ucity/statd;riP)
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 working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
L)-?"am a sole proprietor, general contractor or h�Wore�s circle one) and have hired
the contractors listed below who have the followinompensatio n policies:
rime of e ontractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contra(ztor) (Insurance Compaay/Policy Number) (ExTp m6oa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expii lion Date)
(anaclr zmticcz d s_hcc if neceztiry to inc}u<4e information pertaining to 911 00c±Mtior3)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pleaae be aware that while homcowixra who crnpiay per: to cio maiatcnln;cez rue on er rcoau worst on a dwelling of
not more than throe units in Atvclt the hovnoouvcr residd or oa the grounds zppur m r t thereto erc not gccxially toe &rod to be
cmployrra under the%vo6-es ccarper=tion Act(GL152,n l(5)�npplication by e homooavcr for a Ucerise or pmnit may cvidcaoc the
legal ctahre of an amployor under the Woriccet Compauation Act
I uadera=d that a copy of this axtcmcat may be forwarded to the Dcpe tem of Indiutriel Accid=dy oflioo of lasura000 for tho
coverage vaificatioa and that failure to Sea=covcntgo trader se,i on 25A of h(GL 152 can lead to the imposition of criminal pcaaltics
ootnistiag of a fma of up to S 1,500.00 ar.Nor imprisoaaxat of up to oa year and civil penalties in dx form of a Stop Work OrdC and a
firm of 5100.00 a day ig�tiuA ttx
For deputrrx��uao only
llG� c �{t Number Lot 4
O
Signature of Licrosee/Permittee e
r
SECTION 8'-'CONSTRUCTION SERVICES`
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�}2 Isteed.� pro emenipntacto ,« E: iE
;�.�, Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
FI -� fr �om O rig � i. .n.
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 responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning aws and State of Massachusetts General Laws Annotated.
omeowner Signature ti
-s
SECTION 5=DESCRIPTIONf OF PROPOSED"WORK(check all applicable)
m,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6 If Ne�ni horase and omil ��dclition to existing ho�usin ,.cornpM6',the:f61 lo:Wi t:
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?
In. 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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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
1 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
Signwner/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 /a l
Side L: R: L: /07 R:f u
Rear
Building Height
Bldg. Square Footage 41�v % �p�U
Open Space Footage % T
(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 N0�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
1
IF YES, describe size, type and location:
Y.
Giy rrf Northampton 5
din ,V i B6,ftding Department u
' —1212'Main Street ►
_
Room 100
$ 200&ort6fnpton, MA 01060 ets.of a
phone 413 1587-1240 Fax 413-587-1272 PIo It�ePa,
LA-P-PLI-C-AT-ION- C0NSfiRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING `
SECTION 1-SITE INFORMATION
This section t94beicompleted"tiyfoffrce�
1.1 Pro ert Ad ess: l� ,
Map
Zone^ O�ertay�b1strict `
_
Elm St. District' CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
.1 Owner of Record:
Na T4
-
(Print)" Current Mailing Address:
k( d
1�
�(1Z4C �`' Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
comp) ted by ermit applicant
1. Building (a) Building Permit Fee 0 00
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
zjo-
This Section For Official Use Only
Building Permit Number: `7�_ Date Issued:
Signature:
Building Comm i ss loner/Inspector of Buildings Date
File#BP-2002-0973
APPLICANT/CONTACT PERSON DOYLE EDWARD F&SHIRLEY S
ADDRESS/PHONE 65 REDFORD DR (413)586-0095 Q
PROPERTY LOCATION 65 REDFORD DR
MAP 36 PARCEL 053 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out 4a ek
Fee Paid
Typeof Construction: ERECT 12 X 10 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Co on
&12co L
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-2002.0973
GIS# COMMONWEALTH OF MASSACHUSETTS
4 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-0973
Project# JS-2002-1571
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor_
Lot Size(sg.ft.): 12501.72 Owner: DOYLE EDWARD F&SHIRLEY S
Zoning:URA Applicant: DOYLE EDWARD F & SHIRLEY S
AT. 65 REDFORD DR
Applicant Address: Phone: Insurance:
65 REDFORD DR (413) 586-0095 0
FLORENCEMA01062 ISSUED ON.5 110102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 12 X 10 SHED
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 5/10/02 0:00:00 6912 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo