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I �f�w hI a► f 0� , � -� �g 4', . a NOV 2 0 2000 k �0Q� TOy ----_ e (CZ J UlfIIl" I��i111�7 II1i B 6 f3ltsaxchnsrtta m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'o Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFTEDAM p -- Nccnscc/permittcc) with a pi-incipal place of business/residence at: ° _s S=06 12— (stir;t/ci'f}'/stai�iap) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing, the following workc,-'s compensation coverage fol Illy employees wor mg an tlns job: �j--- (=dl--nce (Polio-Number) (Ex-pimtion Date) O I am a sole prop,ictor, general conts-actor or hoinco%vner (circle one) and have hired the com-Factom listed below vti,ho have the following worker's compensation policies: (Name of colltrlctOr) (Insurance Company/Polic},Number) (Expiration Date) (Flame of Contractor) (Insurance Company/Policy Number) (Expiration Dale) (Name of Contractor) (Insuran(-- Company/Policy Numlkr) (Expiration Date) (Name of Contractor) (Insurnce CoMDary/Policy Numlhs) (Expiration Date) (attach additiocul sheet if ncxsury to�x Udc mfocmitioa per--2z niig to al]coa me on) (.� I am a sole proprietor and have no one worldng for me. ( ) I amt a home owner performing all the work myseff. NOTE:plc-sc be acrarc that"'bile homcouvcrz wLho emplay pcsom w do,-,.==13 z 030s:�oa or repair\Nwk on a dv.cll of not❑loco than Lbr�snits in which the hon»owu<r r=dca or oa the gounhs appurten+nt thcrs arc oot wally ooasidacd to be cmploycra tttxl[Y the workt,s cacnpcasatioa Act(GL152-s 1(5)),application by a homcowrxs for a bccwc oc puma may-I&—the legal etatus of an o9ployec under-tho worlcoet compomatioa A x I underita duct a copy of thin stet—Cif may bo forwarded w tha DeQertnmt of Industrial Ad—&Offioo Of lrrsvr,<noo for the oovcmgc vcrificatioc and that fall=to acalrc oov,.a under scczioa 25A of MoL 152 can lrsd to the iutpositioa of criminal pcaalt' oomi-Ving of a fmc of trp w S1,500.00 and/or iooprisovnxat of up to one year and Civil pcatttia in the form Of ft Stop Work Ordcr and a fins of S 100.00 t day tgninst mr For dqurtmrdal uic oolY Permit Number 6�sss kP G�( ZO'ZtJI. Map,- ----Lot 4 Signature of Ltc=Scf/PCrrilitt(x -- -------- �� SECTION 8-CONSTRUCTION SERVICES ,.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : /� cal i9�✓ .� � %/ License Number 1 ,7 Address /, &M012 Expiration Date Si ture Telephone Not Applicable ❑ :20m .J/,mow e/l f'xtrl Company Name Registra ion 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. igned Affidavit Attached Yes....... ❑ No...... ❑ y 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 ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: lVe-, 3 pY'A P-oi Alteration of existing bedroom Yes_3Z No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ <. 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? 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 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 �lf �j r-+� -�—�" 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. igned under the pains and penalties of perjury. Print Name ignature of Owner/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 Frontage Setbacks Front Side L: R: L: R: 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: City of Northampton Building Department t 212 Main Street z Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION This seta©n to brsm e pleted by off,," ; 1.1 Property Address: e Sf��°�— Map Lot Unit Zone Overlay District Elm St. District C8 District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Dlaxle C2. L34I�G'S 3 T/fCcT Name( ri ) Current Mailing Address: Telephone Signa ure Z// Z.O 2.2 Authorized Agent: 7o.*1 �7ols�� GerlrroG Carr/arocfa2 ��2 �ovrl, rt �Lirffri� ���� Name(Print) Current Mailing Address: 4'/3 - SBs=06 i Z Signature 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 2. Electrical (b)Estimated Total Cost of o °Construction from 6 3. Plumbing �i 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: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2001-0511 APPLICANT/CONTACT PERSON THOMAS DOLAN ADDRESS/PHONE 172 SOUTH ST (413)296-4303 PROPERTY LOCATION 19 BATES ST MAP 25A PARCEL 160 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: CONSTR CT EW BATHROOM WITHIN EXISTING MSTR BEDROOM New Construction Non Structural interior renovations Addition to Existing Accessoa Structure Building Plans Included: Owner/Statement or License 039281 3 sets of Plans/Plot Plan T OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 Commis ' Permit from CB Architec e C mmittee 1 ;�7� L00 a 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. 19 BATES ST BP-2001-051 1 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25A- 160 CITY OF NORTHAMPTON Lot:-001 Permit: BuildinA Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-051 1 Project# JS-2001-0879 Est.Cost:$14370.00 Fee: $51.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: THOMAS DOLAN 039281 Lot Size(sg.ft.): 10410.84 Owner: MILLER SCOTT D&DIANE E Zoning:URB Applicant. THOMAS DOLAN AT. 19 BATES ST Applicant Address: Phone: Insurance: 172 SOUTH ST (413)296-4303 Workers Compensation CHESTERFIELDMA01012 ISSUED ON:11 121100 0:00:00 TO PERFORM THE FOLLOWING WORK.-CO NSTRU CT NEW BATHROOM WITHIN EXISTING MSTR BEDROOM 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 11/21/00 0:00:00 3137 $51.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo f { v: h r 4�e t. no O 3 4 s 4 !fit ova W � t a l k ., 77, VIA of { i pt ty � f t � z i { P OMAN t#r �. TO 7777:77'77�7 f VIA n ANN lot IQ SAW OWN I Was �a 3 r low, fQAT>f r ST MIAMI of " r... „ WK A low VMS%.Y _ MAR W_ . 19 BATLS ST BP-2001-0511 #; CO TH OF l A S ABC JS T"TS M M%k;2SA►, 160 C-IY Of NORTHAWTON 'Pentit, . �.<•�y �. JS-2001-0879 Fst.Ctt;�143?�.tlf! G�nst.Blass; +t�xb�t�tttr: .I�,�;serrse: tlr Inman: THOMAS DOLAN 039281 sizefscn ft 1 Q419.84 Uw_ner: MULt. Ca » > �E a X45 QQLAN can drexs i'lri e, arameu ra 42z 9T 413. -4303 Cs�tion C HtS1 RP1ELDM1A0101 Wit_ t ! ' �' '1 'r 1 $i 0{)NTRt1CT NEW BATHROOM WITHIN M4 TR ise ROOM } V InIF 8f �1 ilH I for of i in .P.W: : I�tor of Bnij3np rlle Un€�nn : Meter. R4uh; 0A Flash i vt Sl: ♦ ✓ 19;a AWReugh Fine• Caa l rtment FireplaWChimney: *' Insulation: `"' 'do Final:0 MAY AtUVOXED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF RGILTONS• . f 3 I3 t1 11/23/4ii 6:00* 3137 SSl.i 212 :. lone(413 5,$ -1240 OX(M 587-1272 Buu i loner-Anthony P"q