36-271 $ � ;,�. 7 Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
MUST INCLUDE:
Site Plan -ZFloL Plan - Showing all buildings
TtT h square footage and distance to property
-�� lines:
�iling deadline�is Wednesdays by noon
R�viewed every T6rsday
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12 10
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 "
WORK-ER'S COMPENSATION INSURANCE AITTDAVIT
(li censeeJpermi tt ec}
with a principal place of business/residence at:
(phone#)
(stream ty/stalfJrip)
do hereby certify, under the pains and penalties of perjury, tliat:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Iasu.rancc Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurancc Company/Policy Number) (Expiration Date)
(Name of Contractor) (lnsurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poticy Nuulbe-r) (Expiration Date)
(Name of Contmctor) (Insurance Compzmy/Policy Numb,,-r) (Expiration Date)
(atiadr additi coil s!xct if ncccrrir;.to ixludc inforttuti ocr pertaining to all cxatradors)
( ) I Lim a sole proprietor arld have no one wor4dng for me.
',-'I am a home owner performing all the work myself.
NOTE:please be agars that wl„i]e hca)eoAnxt3 who crnplay pc z m to 63 c�inlciiacr,eo--=c�-Ien cr mpairµotic an a&selling of
not mac than thtca un tt in tst di the ho xouvcr mida a oa Ltie p ov, ,zppurteraat thesdo a.'c net�cz illy—i i red to be
eatploym under the% orka'a coagx-s— tien Ad(GL152,,-s 1(5)�applintien by a homco Ana for a ticcrzte or pmm t cuey evidence the
Ic9a1 statue of an employor under the Wortccc'a Compematioa Act.
I undentsnd clot a copy of this stnicmcut msy bo forwnrd«d to tbo Dcpartmcuf of Inhu_strial Aoc,& rte'Offioo of Iii-lu-for tha
coverage vaificadoo and that E&dure to st-a=coverago under sectioa 25A of bIGL 152 can lead to tha imposition of criminal pcnalLCs
ooasittiug of a fine of ttp to S'S00.00 arid/or impriso=mt of up to one ytar end civil pcaaltia in dx form of a Stop Work OrdG and a
finer of 5100.00 a day a 3n—
Foeartmcidnl uio only
/ Permit Number
Lot#
hiap;t
' ' `` Siguaturc of L' errnittee .
SECTION 8- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
«!5w�*..�..��- a�,:e-fr� C `ter '?c K s�K'Y� a - #.��r� �: �
9Registeredrlme, merovement&Contracto`r'. , , , _ kt;,, �_, ,,; ,,,s,,�_. . ., .., Not Applicable ❑
Compaq 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....... ❑ Nc. .... ❑
11�-IT MO w f6ffW--JAion
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 to-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. I
The undersigned"homeowner" certifies and assumes res 'onsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local loping .aws nd State of Massachusetts General Laws Annotated.
Homeowner Signature _ _ �`
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. X Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ J
Brief Description of Proposed Work: r x 2 Sit
Alteration of existing bedroom Yes_ No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
66i If New house" a id='°or#addition=to:existing tiotasinfY; complete-thilD 6 ovi%Ini7:
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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize ._ _.__ to ac, or
my behalf, in 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'nd penalties of perjury
Print Name I 7—Z�-'Z_
Signature of Own /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 2 S Pl e✓' o �61 ou"o
Frontage �� / 195'
Setbacks Front 40
Side L: R: L: �U R 46
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 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:
f (
�+ f Northampton
! ing Department C
Main Street
'Room 100
N6 pton, MA 01060 e. a
phone 413-58T1240 Fax 413-587-1272 5 t
APPLICATION�TOb T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This setlo Ito becompletedyby office
1.1 Property Address: >*,
OG
' MapLot zUnit
Zone, �L* Overtay�D�strrct
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
VIAI (IF
j -- IL12
Name(Print) Current Mailing Address:
?elephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature i Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
Z
2 Elecirical (b) Estimated Total Cost of
Construction from 6'
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5) Check Number p —
This Section For Official Use Only
Building;Permit Number: —"0 _ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0416
APPLICANT/CONTACT PERSON EPSTEIN KEVIN G&
ADDRESS/PHONE 168 MAPLE RIDGE RD (413) 584-0590 Q
PROPERTY LOCATION 168 MAPLE RIDGE RD
MAP 36 PARCEL 271 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out alga
Fee Paid
T_ypeof 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
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQqYddATION 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 C ssion
o 12,
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.
a
168 MAPUf URGE RD BP-2003-0416
GIs#: COMMONWEALTH OF MASSACHUSETTS
ax B-1,
lKk:16-271 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0416
Project# JS-2003-0705
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 94089.60 Owner: EPSTEIN KEVIN G&
Zoning: S Applicant: EPSTEIN KEVIN G &
AT: 168 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
168 MAPLE RIDGE RD (413) 584-059Q ()
FLORENCEMA01062 ISSUED ON.10124102 0.00.00
TO PERFORM THE FOLLOWING WORK:ER E C T 10 X 12 S H E D
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 10/24/02 0:00:00 1319 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo