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25A-121 a MAN A VE S58'08'24"E -- __ -- 50.00. co Q J J 3 y� z Z cv co Z b ZLL z 16.9't (r Y J t � 3 z s F 15.4 f t t p N d � � = M N _ }-- co Z z `r•° 7a N rn O i`- V � z N53.05'1 4"W 66.33' w Z J J Z 'Q U 2 ��, w.,,,n•7M � 4 � { f Y » '4. alxx a i fl f � i s fJ s • i � ��ui A4'�+ i 1 � , i - • 4.titAl�fP�O 10 M 9 g CHi for II #Ej�l1Y�7 IItt ae �asaafflaattla DEPARTMENT OF BUILDING INSPECTIONS ' 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORKER'S CONMENSA ION INSURANCE AFFIDAVIT (li txuserJpermi tree) with a principal place of business/residence at: .e ', /`7ft (phone#) (stxcWcity ap) 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 wolfing on this job: (lncstranCe 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 workees compensation policies: (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) f. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) ('Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additiocal sheet ifnoocssary to information pertaining to all maunders) ( ) I a sole proprietor and have no one working for me. ( a home owner performing all the work myself. NOTE:please be aware that while homoowncrs who employ person to do I Eafm.ru c ccnitnsd oa cr repair work ou a dwelling of not mode than throe units in vainch the bo=» wncr resides or on the grounds appurtenant thacW uc not guxrally ooandered to be cmploym under the wockces coaVcau4cn Act(GL152.ss 1(5)),application by n homcoworr for a be==cc permit may-id—the legal etsuva of an employer under the Workces Compemation Act I undasuad dut a oopy of this rtoxmmt may be forwarded to the Dcpartmoot of Ls�al AD6&. 'Of oe of lnvm*. o for the coverage vaificatioa and that failure to scone coverage under section 25A of MGL 152 can lad to the imposition of aimin+l penalties ooasutin of a fine of up to S 1,500.00 andlof im{ttisarmxrtt or up to one year and civil pmxWes is the form of a Stop Work Order and a fins of 5100.00 a day agniast ma For dgmtm-lw use 4°ly 47 T Permit Number �44 � �G''�)h Map-4 Lot# Simature of T.ir~- io :rr ? c. 0 SECT�b -8 CON5�TRl CTION}S RYICES 8.1 Licensed Construction Supervisor: Not Applicable B�- Name of License Holder License Number Address Expiration Date Signature Telephone v men n r r, g Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECT,ION`10,'WOR3KERS!COMPENSATION INSURANCE AFFIDAVIT(M:G L.C. 152, §25C O)) 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...... ❑ 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 d Local Zoning Laws and State.of/Massachusetts General Laws Annotated. Homeowner Signature t �i✓ z�SECT�O�N�S �DE CR�IRT OIV �PR�OPO�SED!��YI%���� cFi`eck�'a�ll�a licable �'� :,mvx,,3 ,h,�fi' iKgi'd 'a� i fiat. ,k..mh New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ] Brief Description of Proposed Work: i sT 1, Tz Alteration of existing bedroom Yes_ No Adding new bedroom Yes /-'' 10 Attached Narrative❑ Renovating unfinished basement _—Yes ✓-No Plans Attached Roll ❑- Sheet o Gf Ne ' se fid WWdiiiifion fa zisting W—U—Ti eAld npI"e e; 'ie` 61MWlH : 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. 0,7a Dimensions e. Number of stories? f f. Method of heating? ` ,f Y ,Fireplaces or Woodstoves Number of each g. Energy Conservation ompliance. 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 (I'-' k. Will building conform to the Building and Zoning regulations? a ` Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION Za OWNER'AUrtHORIZATION TO BE C©MPLETED WHEN OWN,ERS'TAGENTOR CONtRACTOR AN'PI.IES FOR BUILDING PERINIT I, 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 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 pe Ities of perjury. / PLx/ G AG z C3 a< x'111)'aV` Print N me Signature of Owner/Agent Date c 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 �� , S a Side L: D, JR: y L: R: Z: , (/ Rear �D Lj o Building Height 6/ Bldg.Square Footage /0 jo Open Space Footage % (Lot area minus bldg&paved parking)�J #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 t.--' 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: ... _ nri ESL"'a> '�i a�.C�lS�45 S,'i-ivwe:•:n..?<q.w: 'a6:.e..:',i.. _ :.v....:..............w.w. . 1 i(n ditybf Northampton —�Buifding Department ' ? G2 , X112 Main Street 10- Room 100 a Northa pton, MA 01060 ph` ' 4is3-58 -1240 Fax 413-587-1272 P"a--Ste ( er `peo .. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING :SECTION 1-SITE INFORMATION hi' sb'fion'fo be co`mple,ed b ofif[ce` ` 1.1 Property Address: „ z / Map _ o fX5 Y ' -n EV EImSt District', CB r-c SECTION 2-PROPERTY OWN ER,SHIPIAUTHORIZED AGENT 2.1 Owner of Record: / Name(Print) Current Mailing Address: r~ ' Telephone tg Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SE6TiON'3 !ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Off icial Use'Only completed by ermit applicant 1. Building � ��� (a) Building Perm'it 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 Section For Official Use Only Building Permit,-Number: Date Issued: Si,gna#ure: Building Corrimissioner>Jnspe, for of Buildings Date, File#BP-2002-0961 APPLICANT/CONTACT PERSON WILLARD TODD ADDRESS/PHONE 6 SHERMAN AVE (413)584-7035 Q PROPERTY LOCATION 6 SHERMAN AVE MAP 25A PARCEL 121 001 ZONE URB 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: CONSTRUC 20 X 12 1 ST FLR&4 X 8 2ND FLR 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 INYFOPPIWAIATION 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 Pemut 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 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. µ � BP-2002-0961 GIS#: COMMONWEALTH OF MASSACHUSETTS -_ CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2002.0961 Project# JS-2002-1559 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq.ft.): 10410.84 Owner: WILLARD TODD Zoning: URB Applicant: W I L LA R D TODD AT. 6 SHERMAN AVE Applicant Address: Phone: Insurance: 6 SHERMAN AVE (413) 584-7035 0 NORTHAMPTONMA01060 ISSUED ON:5114102 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUC 20 X 12 1ST FLR & 4 X 8 2ND FLR 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 Sisnature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/14/02 0:00:00 1822 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo k AM y my"Wi RAW KJ L�t v -, ,- ° r'"x' ;.r< -ww•"' ;rte .d .s `�,z> ' �y a ToOl 6 SHERMAN AVE " ' GIS#: COMMONWEALTH OF ��� AC�USETTS Map:Block:25A- 121 CITY OF NORT' PTON • Lot: -001 Permit: Buildini? Category: BUILDING PERMIT Permit# BP-2002.0961. Project# JS-2002.1559 Est.Cost:$3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License. Use Group: Homeowner as Contractor_ Lot Size(sa. ft.): 104 10.84 Owner: WILLARD TODD Zoning:URS Applicant. W 1 LLAR D TODD AT. 6 SHERMAN AVE Applicant Address. Phone. Insurance: 6 SHERMAN AVE (413) 584-7035 (� NORTHAMPTON MAO 1060 ISSUED ON:5114102 0:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUC 20 X 12 1ST FLR & 4 X 8 2ND FLR 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: Df� Rough: Rough: House# Foundation.,,, Driveway Final: Final: Final: Rough Frame: B'.w Y&-/j, - Gas: Fire Deuartment Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: OX !O-3l cow THIS PERMIT MAYBE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULATIO S. Certificate of Occupancy Signature: Fee Type: Receipt o: Date Paid: Check No: Amount: Building 5/14/02 0:00:00 1822 $50.01 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo