36-045 (4) `O 4-�ttAAfp�O
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m DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton; Mass. 01060
WORRER'S COMTENSATION INSURA-NCE AFFIDAVIT
1,
(licenserJpelmittee}
with a principal place of business/residence at:
(phone#)
(&t=Ucity/stalelyp)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working 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 Numbcr) (F)irntioa Date)
1r
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (a--piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additioml Sheet ifneccuiry to include informtboa pertaia.ing W all o`atractor3)
( ) 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 while homeowners who cmploy pa-.ors to do maj•,�a�oo cr repair wvcic on a dwelling of
not mace than throe unit,iA which the bomoownct sides or oa the grov zppurtanant thej t arc oct generally oocsidcad to be
cmploy=under the works cca�oa Act(GL152,s3 1(5)),applicabon by a homcovv=for a hccasc a permd may cvidcacc the
Iegzl stxtara of an ernployor under tho Worlcods Compoass ion Act_
I uadaitand that:L copy of thin ctatcoocut may be fotwnrciod to tbo DV tmcni of 1.&shial A.6&-&Offioe of Irnx—for the
coverage vaificatioa and that failure to sown coverago undx soction 25A of?40L 152 can Icad to the imposition of criminal pea Wes
ooasist utg of a fine of up to S1.300.00 and/or imprisorrmazt of tip to oix ytrr and civil paultia in the form of it Stop W orlc Ord, and a
fmo of 5100.00 a day against me
For dcp�trso only
permit Number
�& { Lot#
4 :, Signature of Licrosedpermittee e .
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Rs ete TIb p. 've en ontr 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......
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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
J, a a ,' 1X .a-zsa�d,..��.3�3'�n ,N.r_W „ni ,.. ;, ,. a
SECTION 5 DESCRIPTION-,OFiPROPOSED WORK check=all a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ge Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: c e d �� Fog
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6 ff lNeVIK009 a and"o ` tldition t°o eirrstingahousirig;�corriplete3 h :<fol'fovrff
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 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 OWN ER`AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS" AGENT OR.CONTRACTOR-APPLIES FOR BUILDING PERMIT
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
A) j6APA AV-A- IJ1,0G WS 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.
KeAI A)M r' &Wto &P-A- ,&)Vn t XS
Print Name
Signature of Owner/Agent Date
Section 4. s s
ALL INFORMATION MUST BE.COMPLEI(iD,--or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATjiI�
41
Existing Propos Required by Zoning
G This column to be filled in by
Building Department
Lot Size �-
Frontage
Setbacks Front c�
t7//yl
Side L: R: L:Rear J
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 V'
IF YES, describe size, type and location:
iJ t f Northampton
D i ng Department
SEP 17 2002 Main Street S
oom 100 a: "
tha pton, MA 01060
pLP10F BUIl�tlijlAtUf1 -587- 240 Fax 413.587.1272 Pt f te. a x
NORTHAM I� h
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -`SITE INFORMATION
This section,tobecomplete"d.by office
1.1 Property Address: X
a r <
Q le.to� Zone F � �'� Overfay�btstricts� � � ;
yly L" �
r
Elm St. District" CB District `
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record: f��Qr ,nfj
ke lx�+ --,AAAfFR s t��,rd�� �� ° 't�. A 60�f�� t�td�z
Name(Print) Current Mailing Address:
A — g6
Telephone
�(
one e
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
completed by ermit applicant
1. Building via (a) Building Permit Feb
,00
2. Electrical (b) Estimated Total Cost of
Construction from r 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5)
Check Number e �
This,Section;For Official Use Only
Building Permit Number:_ Date Issued:
Signature:
Building.Qommissionerllnspector of Buildings Date,:
s
File#BP-2003-0278
APPLICANT/CONTACT PERSON ANDREWS KENNETH R&BARBARA A
ADDRESS/PHONE 11 WINCHESTER TERR (413)584-1886()
PROPERTY LOCATION 11 WINCHESTER TERR
MAP 36 PARCEL 045 001 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: REPLACE EXISTING 12 X 8 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 ion
c2l, 20c)
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 2003 0278
CIS#: COMMONWEALTH OF MASSACHUSETTS
: xy CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003-0278
Proiect# JS-2003-0481
Est. Cost: $1785.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 10018.80 Owner: ANDREWS KENNETH R&BARBARA A
Zoning.URA Applicant: ANDREWS KENNETH R & BARBARA A
AT. 11 WINCHESTER TERR
Applicant Address: Phone: Insurance:
P O BOX 60492 (413) 584-1886 ()
FLORENCEMA01062 ISSUED ON:9124102 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE EXISTING 12 X 8 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 9/24/02 0:00:00 7991 $20.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo