36-251 (2) E c E 9 v E
414 A
Ull
M AY 7 2001
DEFli OF BUILDNG INSPECTIONS
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER' CO ENSAON INSURANCE AFFDDA'VIT
with a p ' cipal place of business/residence at:
�JG��a 'Goy ��/CU �' (phone#) S� Y` S��1 G
(stMet/city/sta&2iP)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
-(Insurance Company) (PolicxNtrmber) (Expiration Dam)
( ) 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 Numb--r) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(at-+additional shed if neocumy to iooludo inf« oa pataiuing to all oodmdors)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:picric be aware that while homeowners who employ p=-so=to do a gym•ner_construction or repair work on a dwelling of
not more than throe units is which the honmowner resides a on the grounds appurtenant thereto are not gcnaally 000nda d to be
employers under the worker's comp as4oa Act(GL152 ss 1(5)�application by a homeowner for a lio=c oc pcf-a may cvidcnce the
legal etatua of an employer under the Wor r z Comp ozeion Act
I understand that a copy of this zu fement may be forwarded to the Deputmwd of Luhuhial Accidents'Ofoo of Inxuaooe for the
covaxge verification and tbAt failure to aeatre coverago tinder section 25A of MUL 152 can lead to tba imposi -of criminal pwaltiea
ooqustiag of a•fine of up to S1,500.00 anNor imprisotm of up to cue year and civil pmatties is the form of a Slop Work Order and a '
fm of 5100.1)0 a dit against
For dgnutwWW use arty
P.ci tNumber
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'5 Map# I #
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SECT[OWIS CO�S�' Q , �R111C�S ,
8.1 Licensed Construction S ervisor: Not Applicable ❑
Name of License Holder: �,_ C
License Number
Address Expirn bate
Signatu �i Telephone
i
r
' Not Applicable ❑
Company Name Registration Number
i
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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......61 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 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
E C b is b e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks ] Siding[ ] Other[ ]
Brief Description of Proposed Work: SIL \ ,1
J
Alteration of existing bedroom Yes No Addirl.g new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
u ift-OMMMIff-Rh MW
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
SEGTIdN 7a 3fO ER AITtIORIATION WHEN
fWNI=IBS # ?C "I2ACTt AIpLIEQF BUI 't�ING Pk7MIT
as Owner of the subject property
hereby author' e1 d'C��1 to act on
'
my behalf, in atters rela ve to work authorized by this building permit application.
Signature of wner Date
as Owner/Authorized Agent
hereby declare that the sfatehi6nfs and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under th pains ay4 penalties of perjury.
r
Print Name
A�r/�7 h
Z Lr�
Signat e o wner/Age 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
d Building Department
Lot Size
o? A, 30, 61sa
Frontage S
Setbacks Front
Side L: R. LN R:/.S-0
V /
jo
Rear `(D
Building Height 3 `5—
Bldg. Square Footage a 600 % �i �'y aCz)
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. aass a Special Permit/Variance/Finding ever been issued for/on the site?
y
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 wa er or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtaine om the Conservation Commission? C 7
Needs to be obtained Obtained Date ssued: <.'
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_
N ct�
IF YES, describe size, type and location:
5bom Northampton
Department
a i n Street
k ' 4001 100
Nor ham ton, MA 01060
(1ra'Of Sul I PE
87-1240 Fax 413-587-1272
WPTOM MA 01060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This sec#�� ytc 1 #ed +�I I
1.1 Property Address:
MapLo# '�s1lrttt
� �..
.�,
EIm;S2. District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
T�e)7 I., ( A � u C_<� M
Name(Pr Current Mailing Addr _
Telephone
Signature
2.2 Authorized A e :
Name(Print) A Current Mailing Address:
Sign e Telephone
SECTION 3 - STIMATED CONSTRUCTION WI'ffi S
Item Estimated Cost(Dollars)to be Official.Use Only
completed by ermit applicant
1. Building � ��' (a) Building Permit Fee
2. Electrical (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,,Seeld6n'For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0932
APPLICANT/CONTACT PERSON Kim Rescia
ADDRESS/PHONE 311 Locust St (413)584-5816
PROPERTY LOCATION 21 MAPLE RIDGE RD
MAP 36 PARCEL 251 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 14 X 9 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: _
Owner/Statement or License 022464
3 sets of Plans/Plot Plan
I E LOWING ACTION HAS BEEN TAKF
Approved as presented/based on information
Denied as presented: C` +X
� t
Special Permit and/or Site Plan Regi
PLANNING BOARD
Received&Recorded at F + •�
Finding Required under: §
Received&Recorded at Re;
Variance Required under: §
Received&Recorded at Reg_..,., rramEnclosed
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 Commissi6l Permit from CB Architecture Committee
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.
.: BP-2001-0932
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Deck Addition BUILDING PERMIT
Permit# BP-2001-0932
Protect# JS-2001-1677
Est. Cost: $3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Kim Rescia 022464
Lot Size(sq. ft.): 871 20.00 Owner: ALVES PAUL
Zoning: SR Applicant: Kim Rescia
AT: 21 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
311 Locust St (413) 584-5816
FLORENCEMA01062 ISSUED ON:5125101 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 14 X 9 DECK - * NOTE: STIE
MUST BE STABILIZED A.S.A.P. (PLANTS,GRASS ETC)
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 5/25/010:00:00 374 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo