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R flfinz flfalll}Ifo[t �Zc��achncrtle — co DEPARTI.4E-1JT OP DUILDjr�\'G INSPPCT1011'S 212 Alain Street ' Municipal Building Northampton, Mass. 01060 WOR1Q:R'S COM ENSATION MSUR"CE A AM' (li ccusCdpernli ttcc) urith a principal place of business/residence at (sff�t/c�ty/scat:/ap) do hereby ccrtifj-, under the pa-m and penalties of perjury, .hat ( ) I am an employer providing the follo\ving worker's colnnensZvorl cove Ige for 11)), eluployces wot-�Jng on tills job (Lu-=nc.2 (Polio: Numb--r) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the follo%VinQ worker's coMnenSanon policies: (Name o;Co factor) — - ([nSum Colnpan}'1i'alic, N'um :) (i=xpiracloe Date) _ (Name of Coollac-ior) -- Rnsuranee COMDa-av/Police N;um6rr) (ExpTII-oon Date) (Name of Contractor) Qnsuranc CompaDy/PoL'c� Number) (Expimtioo Date) (Name of Contractor) (InSUI-MCC Compzn},/Pohcy Numbs) (Expit lion Date) (coach addl IX 1l r xc1 lnc�u y to¢Gu nfonn�._i oo rxsta inin�to.L o ar co ) ( ) I am a sole proprietor and have no one wor-Ling for me. ing am a home owner perform all the work myse f� NOTE:plc -Ix e -arc tt,.."L-Jo hoavowo r" to c�play petons to c� �, cos-e� c c�av wor oa.d..clt of ant[ZKXC `l L L'afJ iR%a'b] Lt"t1o�—rtiido or oo tbC©ouo�i zap�ulrnrn. them LT ax Ce- 21Ty oa ;d--d to be tploycs un c Lie'0,:- m ccmP _tioo Act(GLl52.n 1(5)�application try a hoav owv for:bczrr__or permit�y e Idcaoe,L•e Icgal"-of an—ployer under d1 Wu+,ora C�aomai.ioa rid I undcistxad that>Dopy of lhii crztc i may bo(orwaveted to tbo Dc;xirtmcoa of irJ rim d-AY Offi oo of L--for Lbo oovcr'sc vcriLetioo°-'d Lha.t f_iJLze to teauc eovcn under, 1oUioa 2 S A of MOL 157 can Icad to the imposlbon of criminal pcualbcs ooaair,n of a fine of up to S 1300.00—&Cx 6-Tgi3oou�a>i of up to one yr,.Lnd a%iJ pmatua n[`x focm of a Stop Work Otdcr and a fim of S 100.00 t d_y rpimi me For dqr,.-tnr�.il u,c Drily Pt1 II1Jl Nl1IIltX:r Lot Si�naurn of L aiscrJYcnruttcc —D��e 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone £:.<::,. Not Applicable ❑ REMMURM,NU Company Name Registration Number Address Expiration Date Telephone S C 1©N 1Q 1N[dRK F S' ?1VIi�EI�ISAT ION'-11±ISURANCE AFFIDAVIT(M.G.L.c. 152,§2rs0(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 10.8.3.5.1. 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 fob 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 /./.�,CwLl/� l 3; New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ ley X Or Doors ❑ Accessory Bldg. IT Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: / 0 X J A h Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ r � 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? ". 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 S C'1�fQ1 flWN R AiJTk1O fIZAT'QN>TO' i COMPLE ED WHEN OtIE AGN1` 3It„CQN1'IACIrOt PL '>FKf BIfILtl1N 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 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 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 ai 311 ai3 Q omj0-0-° /l>O Frontage /0-0 Setbacks Front d 2. Side L: R: � �� L:_ZO R:� Rear lJ 76 Building Height �Q Bldg. Square Footage 10 % % a lox Open Space Footage % "n (Lot area minus bldg&paved parking) #of Parking Spaces r(cl—ioll"ume&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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SEC°TItNV.1-'Si.TE INF..O-RMATON his 1.1 ProRerty Address: ., 1•„ ,,• a,,.,,s 4 F/ �-' SECTI M 2 IyRC?PER7Y piNNERSAIp/AUTHE�Ri D AGENT 2.1 Owner of Record: 'WA 1z -,�r"clhr S 0,0 Name(Print) Current Mailing Address IC nf0 :S ;elf,C R Telephone signature L S 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone �t"IQ�+ �TIIVIATED C8"NSTiRt1CT1aN'COST` Item Estimated Cost(Dollars)to be Official Use Only' completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Costbf Construction from. 5 3. Plumbing Building[hermit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) Chtecic Number N" its So Wn IF dfficf aM Use l�nl ulldlrl Prrit Niitttfet: Date Issued-' . uld�ng, rrrfssarsr/l�tpetc�r..gf_Ed[idit gs Date File#BP-2000-1149 APPLICANT/CONTACT PERSON JOHNSON OSCAR ADDRESS/PHONE 295 BROOKSIDE CIR (413)IP-8849 Q PROPERTY LOCATION 295 BROOKSIDE CIR �j MAP 36 PARCEL 130 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled o _ Fee Paid Typeof Construction: ERECT 10 X 12 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 THEYLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: ////Approved as presented/based on information presented. Denied as presented: "!* Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § _w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 ission Permit from CB Architecture Committee ?�L L mCU 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. 295 BROOKSIDE CIR BP-2000-1149 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 36- 130 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: shed BUILDING PERMIT Permit# BP-2000-1149 Project# JS-2000-2028 Est.Cost: $1000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sq.ft.): 21344.40 Owner. JOHNSON OSCAR Zoning.URA Applicant: JOHNSON OSCAR AT. 295 BROOKSIDE CIR Applicant Address: Phone: Insurance: 295 BROOKSIDE CIR (413) 586-8849A) FLORENCEMA01062 ISSUED ON.6122100 0:00:00 TO PERFORM THE FOLLOWING WORK.ERECT 10 X 12 S E D 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 6/22/00 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo