25A-131 (5) O
rr
O
n
r
r
R�
X ti
0
V .Z
U] O
N
'17 �
N � z
E N
w
X
a
T-O" V d
n
4, b
o -
cn q,\V
4
0
27'-0"
0
Ul
Id
wz
Im
a\ O
N
ru
to
rq
rho A n ° �• raD m p Q• �y
F-
7 s n
r b o
z 0. °
n
rr
r+•
41
O
'-r
(D
O
n
n
Cr1
X
UG
x
O
CD
18'-10"
X ��t
O
V �
� O
CD G
o � z
0o N
X
N
3'-0" V d
n
b
0
2T-0"
�• N y
;1, Q7 fD o
tD ro � O('� m M fn
tj
. x cn
m N rn w
cl� w a rt n
o
� E 7 0 C m y rt a
y
n
UQ
The Corrrmcrwea%th of Nfassachtrse:ts
Depa:m.en of Indusrriai.4 ccider-ts
D,fzzce oflrvesti?atiotts
_ 600 FT"shimron Sn eet
Boston, AN 0211.11
w Kw.mass g ov/dia
tic orkers' Compensation Insurance _AfUday-it: Builders/Contractors,Tlectricians;'PIIIi-nbers
Applicant Information Please Print Le?ibly
Nanae (Business Omani arion,'Individual):
_address: ,
Cit-y:/State/Zip: Phone= __
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor and I
I I am a empIoyez with 6. New construction
employees (full and/or part-time).* have hired the sub-contractors
?.❑ 1 am a sole proprietor or parmer-
listed on the attached sheet 7. ❑Remodel-L-2
ship and have no employees These sub-contractors have S. �Demolition
working forme in any capacity. employees and have workers' 9. C(Building addition
['.No workers' comp. insurance comp. irctrrance.$
required-]
5. ❑ We are a corporation and its 10_❑Electrical repairs or additions
❑ I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions
right of exemption per MGL
myself. �'o workers' coma. L..❑Roof repairs
insurance required.]f c. 152, §1(4),and we have no 13 ❑ Other
employees. ['-,N-o workers'
comp, insurance required_]
'Amy applicant that checxs box i1 must also ill out the section below showing their worries'coupe satior,policv in_forrration.
T Homeowner who subr.->:t this affidavit indicating they are doing all work and then hire outside contractors crust submit a new affidavit indicadr-2 such.
�Coniractors that c'heck this box mast attached an additional she-et showi.e the name of the satrconaactors and state whether or not those entities'nave
e. ioyees. If the sub-conaactors have employer,they must provide their work.::s'comp.policy number.
I am an employer that isprovidng workers'compensation insurance for my employees Below is thepolicy and job site
information. _
Ins;Sr`.nc°Comp T�;dame:A'.'X5 C_. V%A 0 4/ `V1 tS ti—O fe f L✓a�
Policv 1 or Self-ins-Lic..-T: C-L— t't&,O% 2_oC-,,3 Expiration Date: G � 9
Job Site:address: � � �tI3' City'Starz'Zip: (0Qi t-i- 6f6
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25?_of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLz for insurance coverage verification_
I do hereby cerri4 under the pains and penalties of perjury that the in{ormarion provided above is true and correct.
t� DatEno
e: ( t 2 G3 e
Phone `--�' 6
Qr7 cial use only. Do rot write in this area.to be completed by city or town ojjzciaL
Cin or Town: Per mit,License f
Issuing Authorin-(circle one):
1.Beard of E2alflt '_.Builcinrs Depart.:.ent 5. City;To�i? ClefA '.Electrical Inspector =.P'u=.,bin?InspecT_o;
6. Other
iP sere
C-intacr Persor:: =:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 'D
License Number
-7
Address Expiration Dale I
Sign,664, Telephone
Registered Wifi 0mioroverriefit Contractor:
Not Applicable ❑
7 L C,
O' -;-
Company Name Registration Number I
_732 0 0 ma G oo
nA
Address Expiration to
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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to alfow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as super so�i-,QMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homed :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 lo-r-tw_q fan-ffly dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs-d*re than one home-in. .2 two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Buildin icial,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work erformed under the " in er It
As acting Construction Supervisor your presenceoh the job sl ill�e required from time to time,during and upon
completion of the work for which this permit i.��sued.
Also be advised that with reference to Chap 152(Workers' Compensation) Chapter 153(Liability of Employers to
e to'"lap
Employees for injuries not resulting in Q th)of the Massachusetts General'Laws Annotated,you may be liable for person(s)
you hire to perform work for you and to
permit.
The undersigned"homeowner"ce ies 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [ Siding[p] Other[pJ
Brief Description of Proposed t `
Work: P P w sk � �a OQ �'"��� L' — �•
Alteration of existing bedroom Yes�No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes
No
Plans Attached Roll -Sheet
4.1f New house and ora dition to exisfing haus na 6 6rrioiete the following
a. Use of building :One Family Two Family Other
b. umber of rooms in each family unit: Number of Bathrooms
c. Is th a garage attached?
d. Proposed S re footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetl ds? Yes Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar or below finished grade
k. Will building conform the Building and Zoning regulations? Yes i+Je
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 '
s
1, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative tow rk authorized by this building permit application.
Signature of Own Date
as Owner/Authorized
Agent hereb Clare tha thelt6lements 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 Name
k ' J
S' na re f Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ?_ `` g C�6 /` _
Frontage
Setbacks Front
Side L,_3�; R. .�._
Rear .x
Building Height i, -° f
Bldg. Square Footage % -;LJ
Open Space Footage % _M
(Lot area minus bldg&paved �Lf
parking)
#of Parking Spaces
Fill:
N li j
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES date issued '`
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book Pager _ and/or Document#
" S
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO _
IF YES, describe size, type and location: !
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e
( 1
,City oP orthampton
-5uild' g Department Curb a _
f 12 Main Streetewt+c`A � b1 {` '
Room 100iWet� �1biltt � �
f' Northampton, MA 01060 Tivct�es t4
IT,
-phone 413-587-1240 Fax 413-587-1272 �
AFPLIGTION 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
-0<1 A\./pe Map , # t Lot Unit
one OVerlay District
L)f "D
fnm tt.Ulstrict' GB Distric!
SECTION 2-`PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pri ) Current Mailing Address[
^� C-8 �� 4
Telephone
Signature
2.2 Authorized Agent:
Name(Print) , Current Mailing Address:
Sigabtur Telephone
SEtTI0031 ESTIMATED CONSTRUCTION COSTS .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �j (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=0 +2+3+4+5) ' two D Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0606
APPLICANT/CONTACT PERSON JEFFREY BOTT
ADDRESS/PHONE 32 Pine Street FLORENCE (413)584-6251
PROPERTY LOCATION 51 DAY AVE
MAP 25A PARCEL 131 001 ZONE URB(100)
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: CONSTRUCT 12 X 27 DECK _
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 053157
3 sets of Plans/Plot Plan
i FO O WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION PRESENTED:
pproved 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 Pen-nit 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 Permit DPW Storm Water Management
Demolition Delay
_":X71-4
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.
t BP-2009-0606
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,,ory: BUILDING PERMIT
Permit# BP-2009-0606
Project# JS-2009-000873
Est.Cost: $14000.00
Fee: $64.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq.ft.): 39683.16 Owner: MIHEVC NANCY T&DEBORAH KEHNE
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT. 51 DAY AVE_
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584-6251 Workers
Compensation
FLORENCEMA01062 ISSUED ON:1211812008 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 12 X 27 DECK
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
ANA' OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature: -
FeeType• Date Paid: Amount:
Building 12/18/2008 0:00:00 $64.005220
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo