36-094 (2) a'ro 0-t crf A ns t(�al)1}ltotl _
30 A Ch nt r(t e"
= i
w DEPARTMENT OP DUfLDr7\C INSPECr101.1S —
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOMCER'S COi9CPENSATION NSURANCE :11,I'D AV-1-]'
4w4f
010CUscrJpermj ttcc)
v.�tll a pl-mcipal plat'- of'business/residencc at
(stt/ci ty/slat yap)
do hereby certify, under (he p?XLS and penalties of perjury, .hat
( ) I am an employer providing the follow,
ne work&S comocnsaL3o, cove.-2ge for my
etuplovccs wor�3ng on Lilts job.
Ranirn= Corm.Y) (P0L C- N r) -- F::piraon Dal)
a �hs--te– to eneral contractor r � ri ,- ,
o homeo vne. (cI �, o._e) ?tea l.��e htrea
the contractelow who Have the fokwinQ worker's comoensznon policies:
(Namc of Con'7:1Cior) (hi-a rancc Cotnoan)'PGGc-, ?�'�in'rc;) �-_>:li;dt:on llmc)
- (NL,ne of Contractor) -- (lns-dfane;. ComoaawPol Cy NU_Ml,F) (Exoif lilon Date)
(Name of Conl2actor) (Insurance Comparey PoLic} Numtu) (E:pim600 Date)
(Name of Contractor) (Insurance Compaoy/Policy Numb r) (L-xpu-anon Da1r) .
(etv.clt �ccil r'xc:if acc�ciiry co mc?u inforw.aoa pertn.inins to'ji
( am a sole proprietor and have no one wor4dn for
g me
( ) I am a home owner performing all the work myself.
NOTE:plc b ewuc LE,w1.Je bcc-o.Nvcr3 to coaploy petons w w r a�� Cr rcazu-ork ou.d.•cll_9 of
an( to which Lb,L,,,,-o, o<oa the Q'ouac4l zppurteo.:r1 tb.- LT we Gek::lty cL-crid:ml to be
cmployc�Lire c h .ai cri _lioa tit(GLIS2-�1(5)�appUcnuoo try n bomco,� rcr:bc=<a PICnna n_y nid'DOec tbC
Icgil n 1i<of ea egloyx Lwdu ttw Wocicli ComponxL rid-
I uodcma d dw>Dopy o(thi.m1_my l>o foc__xi•d to l_popartm,vt of Inazw"l&_d—L"OM oo of Ire,r•oco for the
covcrn&c vairctioa and th..t L "Tt to aoauc`oovR..a�undcr suction 23A of MOL 152 Cr.lad to tlx imoosi -of—1-1 pCC+ C'
ooal ing of a rtn<of UP to S 1-300.00 1ndlnr� ��of up to one yCar end civil pcnal',io in t*x form of a Stop Work Ord rind 4
fiTn 0(S 100.00 1 dty Lpiaa ax.
F, u.c only
c PCrmit Number !'
Lot i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervi r: Not Applicable ❑ /
Name of License Holder: �. �- _ C S 0(3(, 6Y �-
License Number
Addres Expiration Date
Sig ure Telephone
9.Regstere`d lair P►rtpravemeritContractor 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...... ❑
11 Home Owner Exeon
rt ti
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other( ]
Brief De ription of Proposed
Work: J
Alteration of existing bedroom---Yes No Adding new bedroom----Yes _—✓No d �
Attached Narrative Renovating unfinished basement --Yes No
Plans Attached Roll -Sheet
6a."If New house and'or addition Y* tirs" housin , '6 oni 'Iete the foil"owiri "`:
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-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
— — '`" — -- ------- as Owner of the subject
property 4 -------------
hereby authorize _--- N' J4
hereby —� — -------------
thorized b this building permit a lication.
6__ 111246r.4 041- L_"- ____
to act on my behalf, in all rfia ers relative to work au y g p pp
Signatu of Owne Date
I,-_------- nft ,9 _ W`!J-- -�-_Z�-----------, as @vffrm/Authorized
Agent hereby d lare that the statements and infoAnation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under a pains and penalties of perj ry.
At
Print Name
Signat f pwrierfAgent 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
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin
#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:
t
— sir' Depal�tll1 �1F�'PQrII aax4CT
-- f am ton Stausahe�rxttt
amp ton �a�°x
U1� uil rtment �f� lttdrY2Vit P�Ettt � ay k
212 i T� lt r eet ever/Sitrc�Availabitlty� _ �b� ��
I
RD 0 �r1Ia a y
Ma k 4 n(1 <<7 °x �'"*
I N mp n, 01060
1 phone 413-587-12 0 F x 413-587-1272 PxCSit ' ns"� `�t�
€ W
�i M;7'. ..� S.. rte'. e _ ,. �.. ,....::�tl � i'r 14{.• .r+
AP LICAT ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
ert Address:
`
This section to be completed by office
1.1 Pro
y✓ '"-- . ,
Mats Lot Unit—
Overlay District_
Elm St.District CS District_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED i;;T7
2.1 Owner of Record:
t-1--a cel <
Name( rint) Current Mailing Address:
Telephone w3— �5 —;FT—T5
ignature
2.2 Authorized A ent:
ft K&t —0 0. 4jet-dij
Name( ri Current Mailing Address:
Si a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical `J " (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:------- _---_ Date
Issued:
Signature: ---_
Building Commissioner/Inspector of Buildings Date
MAN�5 i°f
BP-2003.0048
GIs#: COMMONWEALTH OF MASSACHUSETTS
:36-094 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0048
Project# JS-2003-0125
Est.Cost: $3500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 0013668
Lot Size(sq.ft.): 26832.96 Owner: BAKER MARGARET M
Zoning: SR Applicant: KENNETH LYNDS
AT: 851 FLORENCE RD
Applicant Address: Phone: Insurance:
P O BOX 448 (413) 584-9282
LEEDSMA01053 ISSUED ON.7111102 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & S H I N G LE ROOF
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 7/11/02 0:00:00 2165 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo