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' DEPARTMENT OF EUILDITjG INSPI'_CI'IONS
212 Maui Street ' Municipal Buildinf, —
Nor Chnmptoil, Mass. 01060
WORKER'S CON-PENSA'TION INSURANCE Ah'IrMANI"T
C - rY� v1�-� iv�ri
(11� l�sc�.�l��:mittec)
with a principal place of business/residence it
-K -- —,LOS / 1��1/L Ifc - l :�,nc,.)-y/ = 3 35
do hereby certify, under the pains and penaltic' oi rj. that
O I and an employer providing the foaov,,1iw coruhensatl,'n coverage for my_
employees working on this job-.
(Insurance Conpany) (Pelic:Number) (Expimtion Date)
O I am a sole proprietor, general eons,.ctor �'r homeowner (circie one) and have hired
the contractors listed below who have the policies:
(Name of Contractor) Nusnbcr) (Expiration Date)
(Name of Contractor) ORsurancc Corm,:.ayiPoiic; Numb---r) (Expiration Date)
(Name of Contractor) (Iasuranc Coral ar, iPoluy Nusnlx;l (Expir tion Date)
-----------------------
(Name of Contractor) (Expiration Date)
(attadt ilima4-i cct if ncccaz,ry to incjv'dc iafocinitioc-"'-taming:,ail cY<;radnr )
( I tun a sole proprietor and have no one i., o'l k p for ale.
O 1 and a home owner performing all tree v,cr}: r:yself.
NOT:pic,:ac b-At c tlui"vhilc �Nlz '-::play z..z to cr tcYau ,oik cn a dwcUL'19 of
not ntcee th.n if-.roo units in tzii;C!l the l� .ncowncr resides c-C CX1 tlKre'o t:c nx cc--Krally eoari i tcd to be
cn1Pto}as uncicz the tvockcs's a c atim Act(GL152�:s l(5)� by a hoatico,rr for c Lccrz�,ct p7mit nmy aidcncc the
ltgal ctatuc of an amplo}'er under the Wociccla compau Iiou Aci
I understi d th,t a c py of thin dates i uuy bo forw•zudnl to t_'; i>:trutzrni of lnduatriel Accir f O1Loo of Izz vrr<noe for the
Coves-age vaiF cation and that fnilurc to saztrc covcntgo tzr,3 r scc:irz 2SA cf MGL 152 can lad to tl'c i^zpo:tion of cnmi ul Per+Ilia
ooasisting of a fuac of up to S1,500.00 and/or imixisomnaii of up to cT }z a:.i civil penalties in ur f cin of a Stop Work 0I and a
a C y artiin st tnc_
Fcr c;q;uturstal u.c mty
Pc?init Ntunbcr
K Map,
Sil naturc of Liccnscc Pertnittcc D�tc'
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction
�lSuppervisor: Not Applicable ❑
Name of License Holder :J,4-b C_ rx_uL_I_r/ ,zc✓L
License Number
r � �
1' z
2u N ww� _ , 5 � � z s�
Address a Expiration Date
Si911 Telephone
9 Regrster'ed Nomelmprovement Contractor ` „ ,,,.'.� ,„ , „ Not Applicable El
N PH aoci��, �yic�r�� -f IZ� S 6AR-7-�(-/
Com any Name Registration Number
Address Expiration Date
Telephone� > cj-
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......
14 saw
11: � 3oine Owner Exemption
The current exemption for-homeowners"was extended to include Owner-occu )ied'Dwellin s of one(1) or two(2) families
and to allow such homeowner to ngage an individual for hire Zih ess a license,provided that the owner acts
as supervisor. CMR 780, Sixth ition Section 108.3.5.1
Definition of Homeowner: Person(s who own a parcel of lae resides or intends to reside,on which there
is, or i s intended to be, a one or two farm dwelling, attached ures accessory to such use and/or farm structures. A erson who constructs more �n one home it od shall not be considered a homeowner.
Such"homeowner" shall submit to the Building f cial, o a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under tX ildin r permit.
As acting Construction Supervisor your presence 1 job site will be required from time to time, during and upon
completion of the work f(,, which this permit is ued.
Also be advised that with reference to Chapt�rtl52 (Workers ,ompensation) and Chapter 153 !Liability of Employers to
Employees for injuries not resulting in Dext11) of the M3SS3chUS is General Laws Annotated, vou may be liable for person(s
you hire to perform work for vou undet;lis permit.
The undersigned "homeowner" certj,es and assumes responsibility t r compliance with the State Building Code, City of
Northampton Ordinances, State`d Local "Zoning Laws and State of Massachusetts General Laws Annotated,
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition El Replacement Windows Alteration(s) El Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ J
Brief Description of Proposed Work: Iq/h K t inr-SU L µ3 '�, w PI E.LS' h f_ v re d (�C t� q /LC C;114
Alteration of existing bedroom Yes No Adding new bedroom Yes No t
Attached Narrative 11 Renovating unfinished basement �Yes No
Plans Attached Roll ❑ - Sheet ❑
sa.f NeWaiouse and or.'addition to existing housing, complete:the 1611 oWihg:
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. —__ P:lascheck 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 'rivate well __-_- -_ City water Supply_
SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ � .
as G.vner of t`ie subject pr oprty
y --- -
hereby authorize �/ �F— 112(,117//lily IZ� t4)iw G— - _.__--- __-- to ac; on
my behalf, in all matters relative to .�;o�k authorized by th �uildin permit application. -
Signature of Owner Date
Y 1
1JZG JZ'I lC +L. or zed Agerntr
as �wr�� Au �
hereby declare that the statements and information on the foregoing application are true and accurate, to test of my
knowledge anp,belief.
Signeffurl, e pa s a d penalties of perjury.
lc' T 14 d L
----- -----
Print Name
-------------------
Signature of Owner/Agent Date
R
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
parking)\
#of Parking S aces
Fill: ..
volume&Location)'
A. Has a Special Permit/Varia'tge/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued: .'
ELY
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
IFYES, describe size, type and location:
1
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;"Al , t Depat� erit s'e "rji °= g
City of Northampton Status ofiPermrt. °
Euilding Department Curb
` 212 Main Street Seiner%Sep;ie a �b r
Room 100 W�aterlWell va ab r '
Northampton, MA 01060 Two Sets of Sti
��hone 413-587-1240 Fax 413-587-12 72 Plof/Site Plans
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 PropertY Address: This section to be-completed by office
Map 3 Lot =Unit
/V C r'l(it v4Iti I r-' U ,,� Zone Overlay District°
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
.1 Owner of Record:
_Lti ry �`c �l u 4 S `1' h 6-r2 S f T r r -!�-
N' rent V . "r( fires,
1 : -- — ---- _
„ign� ure
2,_2 Authorized_Agent; t 1
,�� .�fc �„- /1't v n � � r� •r r'"C.- :2� l'(,�t C-I�c-r r�11 rl�l�v L t� �-� C r �-�'
Nay 1,3 1 rit) rent G>>, ' �rr, Zir1r,�>s
signature
S E C TION_3`ESTIMATED CONSTRUCTION COSTS
tem s`Im tec Est (Dollars'
t Official Use Only
�m�leted by permit arr;`� nt
1 uii�iir (a) E3 ding Permit Fee
2 jai b; timated -il Cost of
�tru icn
from (6) _ -- — -
3. Piumtlwg Building Permit Fee
� Meclanicai (FIVAC; �
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 = 5)� ---
This Section For Official Use Only
Building Permit Number:"-_-
� D<tr; Issued:_._____.---
Signature:
att
Building C.ommissiorler/Ir�sp cctor of Rii�Iding, _ __—_ —-----
__
_.._..
File'#BP-2003-0649
APPLICANT/CONTACT PERSON JADE MORTIMER
ADDRESS/PHONE 28 FORGET RD (413)339-4298
PROPERTY LOCATION 898 BURTS PIT RD
MAP 36 PARCEL 185 001 ZONE SR
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: FRAME&INSULATE BASEMENT WALLS&FLOORS FOR PLAYROOM
New Construction
Non Structural interior renovations
Addition to Existin
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 071226
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9WATION 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 Stree /ornmission
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-2003-0649
GIs#: COMMONWEALTH OF MASSACHUSETTS
low "- CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003.0649
Project# JS-2003-1070
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JADE MORTIMER 071226
Lot Size(sq. ft.): 31232.52 Owner: REYMOND WENDELIN K&
Zoning: SR Applicant: JADE MORTIMER
AT.- 898 BURTS PIT RD
Applicant Address: Phone: Insurance:
28 FORGET RD (413) 339-4298
HAWLEYMA132974 ISSUED ON.214103 0:00:00
TO PERFORM THE FOLLOWING WORK.-FRAM E & I NSULATE BASEMENT WALLS &
FLOORS FOR PLAYROOM
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 2/4/03 0:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo