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f .. .... t� t' zli ,. Ul 3ivcW 30ol '*f Close t 1 � C � • p 4ys r« i ( AV hi s F ��IwrnT 0 4 E Rlc3a itch asclta DEPARTMENT OP DUILD0,IG INSPPCTIONS 212 Main Strect ' Municipal Building ' Northampton, Mass. 01060 WOMKE,R'S COMTENSATION INSUR"CE ArFMAVIT I, -_Soo r-i q PAS-�---- {liccuscJpermittcc) With a principal place of business/residence at: ja3 LNPH _._ 1 _ I TllI pTol�( E Glyf�c-> (phone ) (nr�t/city/statr.�zi p) do hereby certify, under the pains and penalties of perjury, :hat ( ) I am an empioye; providing the following, work-cr's connpcnsarion coverage for rn), eruployces woF.taHg on t}tis job. (Lasurnc-- Coon-=- y) -- — (Pelic: Numlxr) ------ (I xpirtion Daic) ( ) I am a sole proprietor, general contractor or homeowner (Cl.rcie one) and have hired the contractors listed below who have the following worker's comnen-v-ion policies (Name of CO2tMcw-.) — (Irtsumnc Co,npanjP,obc,' Number) O_:plrauon Datc) (N.me of COLIM!Clor) -- (Insrranc Comoaa}vPo!icti Ntr�rcrr) (Expir,uon Date) (Name of Concraclo,) 0-nsuraoc: Companyfpokc�- Number) (Expimuoo Date) (Name of CODU-actor) (Iris=c-- Company/Pobcy Number) (Expifauon Dare) (a[lac�additiomr c?uct if ncc�vry to in�u�uifoc�i.�oa pertn.iaing to nll oodrn�.o:�) O I am a sole proprietor and have no one working for me. (L,i am a home owner performing aH the work myself. NOTE:plcasc Ix aw;-rt Uw wijo hOmColj,VC{]%ibo cmptoy peroni Lo do mx j*-+�axi5=w ioa or rga.c work oz c d%% lli a&of not taaco th_n tbroo twits in which LLB bomoowncr r=d=,x oc the Vv n6:ppun asm thcun an oo(gcoanrry occs dcit d to be employtn tinder the w krr`s owai)c atioa Act(GLI52-"1(5)�apptica6oa by a bomeowwr far e liomsc oc permit may cvideeoc thc Icgil ctnt"of an employee candor dw Wockc js CocapmxLiou AcC l uodcrtwd that a oopy of thij cht—ai my bo focwwded to the p pertmmx of rndux j Aoad-3&Offioo of Inau.00e for the oovcr g vetif ca"0o and th.t f_iture to toc ut wvcngs under soczioa 15A of MGL 152 can lc d to tho=Posiboa of cxuwasr pevallin eoonu m of a fine of up to S 1 500.00 arldrcx of up to ooc year and ei�i1 pmah c,in dx form of a Slop Work Order and a fim of S 100.00 a day c{a.inA me For dcpatrn,-it ui only PcrIILt 1`ttrmbcs _ Map Iot " Sim�tt.m of ccri_krAPcrntitice e A'lt� .-I ",-i, SECTION 8-CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone to 11 eam 'if ettl"'ntG rr' r �t r" :�.._ .. ..E. ._ �: Not Applicable ❑ Company Name Registration Number Address Expiration Date onow SECTION 10-WORKERS' COME /T_ 3 2,§25C(6)) Workers Compensation Insuran, c,%� this application. Failure to provide this affidavit will result in the denial of the is! Y igned Affidavit Attached Yes... Iq ) The current exemption i "A f cupied Dwellings of one(1) or two(2)families and to allow such home ' ' "J, msess a license, provided that the owner acts as supervisor. CMR 7 c� -7 /� / Definition of Homeow ( ��- r she resides or intends to reside, on which there is,or is intended to be, a=e or two tamely 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 -41— ACTION 5- DESCRIPTION'OE PROPOSED WORK(check all applicable) 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❑ Renovating unfinished basement L,- Yes No Plans Attached Roll ❑ - Sheet❑ 6i 1 N e*;,,h 00 vea n ..t�` ddi` 1,onlo ext in 'h' usin complete--'.the foil"o in a. Use of building : One Family_I'�� Two Family Other b. Number of rooms in each family unit: Number of Bathrooms—�— c. Is there a garage attached?---f-� d. Proposed Square footage of new construction. Dimensions e. Number of stories? 1 54-0-me : - IIRCAw f. Method of heating? CJ 14f &i`Y1a 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 I. 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 hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I _157,bN I*y A P oTcl__ 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. ned under the pains and penalties of perjury. O N.i Y A PITT-EL- Print Name Signature o Owner/ ent Date R Section 4. Ohl 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 i/' DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW t/ 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 V 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: r r. Q - Northampton r PON, Buil 'Department % I EJ i 2W21 .a i n Street o m 100 D EFT Oi §n on, MA 01060 etk y 40 Fax 413-587-1272 - th p a APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address: Thps section to becomplIked,by office `Dc) r1 M (HOTEL Map Lot _ _ Unit 1105 PI)ONPHI DR - Zone,, Overla Drs NoRTH0MP i60 M A 0106 0, Elrn St. Distrkt I ce DlstrixI SECTION 2- PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: S�zY�I - PFlTEL ©� J,iiNPtI . 2�IZ _ No�TNr1MNTe►J Mp ab6 Name(Print) Current Mailing Address: LA 1.3- -,--2 6 4!7 0 Telephone Pao 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 com feted by ermit applicant 1. Building O (a) Building Permit Fee �rr�• cc) 2. Electrical OU (b) Estimated Total Cost of Construction from 6 3. Plumbing �i lQ?_�a Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I + 2 + 3 + 4.+ 5) (, Q? oo Check,Number �d This Section for Official Use Only Building Permit Number: 5,00-P 2 S Date Issued: Signature: , Building Commissioner/inspector of Buildings Date File#BP-2000-0958 APPLICANT/CONTACT PERSON PATEL SONIYA ADDRESS/PHONE 103 DUNPHY DR (413)584-6790 Q PROPERTY LOCATION 103 DUNPHY DR MAP 36 PARCEL 180 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid E Building Permit Filled out Fee Paid _ Typeof Construction: FINISH BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan TH OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presentedibased 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 Conservatio mmission Permit from CB Architecture Committee Signature of Building Officia 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. 4 103 DUNPHY DR BP-2000-0958 GIs#: COMMONWEALTH OF MASSACHUSETTS *%ft.Block: 36- 180 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2000-0958 Project# JS-2000-1753 Est.Cost: $5762.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot size(sg. ft.): 14984.64 Owner: PATEL SONIYA Zoning: SR Applicant. PATEL SONIYA AT. 103 DUNPHY DR Applicant Address: Phone: Insurance: 103 DUNPHY DR (413) 584-6790 (� FLORENCEMA01062 ISSUED ON.518100 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Jnderground: 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 5/8/00 0:00:00 198 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo