36-237 Clarke School for the Deaf
Center for Oral Education
SPEECHREADIIVG& OTHER COPING STRATEGILFSunded 1867
This course is being offered again! Participants are encouraged to bring another person, with whom they
want to share information about their communication.
WHAT? 4-session course, facilitated by a licensed, certified audiologist.
WHEN? 4 Wednesdays: 3:30-4:45 PM at CLARKE School for the Deaf
WHERE? Wednesday,M 12, 199 Assistive Devices Center
Wednesday, May 19, McAlister Building
Wednesday, May 26, 36 Round Hill Road
Wednesday, June 2 Northampton, MA 01060-2199
• Please arrive at 3:15 for 1"class only.
GOALS: 1. Demonstrate appropriate use of communication strategies and assertiveness skills,
2. Identify areas of strength and need in speechreading,
3. Identify which speech sounds look alike on the mouth,
4. Practice using strategies and speechreading.
FEE: $ 115.00, payable at first class on May 12, 1999. No additional fee for an accompanying
friend/family member. Course materials and handouts included. Sorry, make-up sessions
not available. Valid MASSHEALTH/Medicaid and Massachusetts Rehabilitation
Commission authorizations accepted on or before May 12.
HOW TO SIGN UP:
Please fill out the bottom part completely & clearly; return by May 10. Thank you!
Name Phone (day)( )
Address Phone(evening) ( )
YES I am interested in registering.
NO thank you, but keep my name on your list for future classes.
Please return to Jaclyn Gauger, MA, CCC/A, CLARKS, 36 Round Hill Road,Northampton, MA 01060-
2199, Fax 413 587-0383, e-mail: adc @clarkeschool.org
Round Hill Road
Northampton,MA 01060-2199
413,1584-3450(V/TTY)
FAX 413/586-6644
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m DEPARTMENT OF BUILDING •INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVTT
(li ct�serJpermitLec) -
with a principal place of business/residence at:
(phone#)
(s ticet/ci ty/statelzi p)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O 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 Number) (Expiration Date)
(Name of Contractor) (Insurance Compam/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaoy/PoLcy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Numbci) (Expiration Date)
(&Mach additioail s!xci if nvxssary to mchu&infocmatjon pertaining to ell eoa rn ciora)
O I am a sole proprietor and have no one working for me.
if am a home owner performing all the work myself.
NOTE:plcaac tx awarc that whilc homcoµacrs who azplay pc=w to do main+�cor�,;Cioa or-pair work on a&N'C ing of
not Moto than thrco units in which the bomeouvcr raids a oa tb.o p-(x d appurtenant thacto a,not gcncraily comidacd to be
employers under the Work,a's ocadpcmatiou Act(GL152.=1(5)),applicz6=by a hmjcoA-=for a license cc pc'm may-id—the
lcgal ctatua of an employor under the Worlcodc CompcouAion A CL
I unaavtimd dirt a copy of this ctat=m A may be forwnrded to tho pc{wrtamt of Industrial Acadca&OfSoo of Imur.noa for tho
oova-age waif tattoo and itut failure to azure coverago under soetion 25A of MOL 152 can icad to tbo imposition of criminal pcnall:cs
oantsting of a fine of up to S 1,500.00 and/or impr isonMCat of up to one)Tar and Civil pcmt6cs in the forts of a Stop Work Order and a
fum of 5100.00 a day against me
For dcputm��710 Ooly
Permit Number
{ Lot#
,,.;.,- r iccnser/Permitice e
... ........ . . ..
SECTION"t--:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
. ...
Rgefis"t�eredt Not Applicable ❑b m , �� �,R
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...... ❑
UYYI: :Ill `., em,I f l .n
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 ocal Zoning Laws and State of Massachusetts General Laws Annotated.
-4<0meowner Signatu
SECTION 5 DESCRIPTIbWdii PROPOSED WORK(check all apalicable)
.� ..1 1k
New House ❑ Addition ❑ Replacement Windows' Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. --ly' Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: �1� �� �d xy 6
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a.'If'New�ho"user"and=ors addition°toezistin tio`usinf7 com'plete�thefollow�n�;
g:
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"0,�2;CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
I,
hereby au rize to ac; on
my be i all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 Na
Date
Signature of Owner/Agent
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 000
Frontage
Setbacks Front
Side L: R: L: 4> R:
Rear G J i
Building Height
Bldg. Square Footage % lea
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 K 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:
i
11221 Northampton g Department Main Street
n
F1 e^T ^' /
oom 100 a er/We ue f,
Notha pton, MA 01060 ToSetso `_�,
it _----P,horae 4-1587- 240 Fax 413.587-1272 Plot/SIte Pan
pLp;Dr g11TDINC,iNSPECIIf!NS O.ther,Speclfy
..APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This-sectiohto be;c'ompleted by office,
1.1 Property Address:
r C �A� dA C-7—' Map Lot Unit
t L
'c'-_ i-t4-- Zone Overlay.District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name writ) Current Mailina
Address-eke-:?v --
Telephone
Sign, re
/ 2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item ; r Estimated Cost (Dollars) to be Official Use Only
_// completed by ermit applicant _
1. Building (a) Building Permit Fee
2. Electrical I� (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) /ca r7 Check Number _
This Section For Official Use Only
Building Permit Number: �d3 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0392
APPLICANT/CONTACT PERSON GURN DENNIS B&JANET C
ADDRESS/PHONE 17 DIAMOND COURT (413)586-3440 Q
PROPERTY LOCATION 17 DIAMOND CT
MAP 36 PARCEL 237 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction:_ERECT 16 X 10 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:
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 Street Commission
e CJ
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.
17 # B P 2003 0392
� CIS#: COMMONWEALTH OF MASSACHUSETTS
lUlanBiac :`36-237 . : CITY OF NORTHAMPTON
Lot: -001
Permit: Buildini7
Category: BUILDING PERMIT
Permit# BP-2003.0392
Proiect# JS-2003-0663
Est. Cost: $3100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg. ft.): 35719.20 Owner: GURN DENNIS B&JANET C
Zoning: SR Applicant: G U R N DENNIS B & JANET C
AT. 17 DIAMOND CT
Applicant Address: Phone: Insurance:
17 DIAMOND COURT (413) 586-344n
FLORENCEMA01062 ISSUED ON.10123102 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 16 X 10 S ED
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/23/02 0:00:00 1770 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo