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w o DEPARTMENT OP BUILDf>\G INSPeCTI01:S ,
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COMTENSA'nON INSURANCE AFFID A FIT
(I1 ccvscrJperrn)r tes)
a plZncipal place of business residence at
N At2_T(�'w^'���u l`'i — �j
SII�t�cl t-Y/Sl alC-1 n
( r P)
do hereby certifj, under the pains aad penalties ofperjury, that
( ) I to an employer providing tfle iollowmst workcr's coil]bensZrion cove"Z!- nor My
etuplcyccs wort.Ilg on tills job.
(tnsur� Coon,v) (Folic; ?vu rr) (L;piraor, Dale)
( ) I aut a sole proprietor, general contractor or homeowner (circle one) and hive hired
the contractors listed 'below who hive the worker's coDpens2rbon policies
Clamc Of Co=ciof) --(lnR!I311C.`, COIT1D171)'/�GUC't' ?��umLY;) �t>>:)1f�UQi1 late)
(Nalue of Contrac10r) (Insrllance coumanv/P011tit' N'utncsr) (Lxpu,iron Date)
(Name of Contractor) (Insuanc: Compan)•/Poticy Numbu) (ExpuTio n Date)
(Name of Contractor) (1nSIImnc--
(eaa h noc(xr Ci on mn{p:_ny/Policy Numbzr) (ExTU-anlon Date)
ddicoc l J � to u to 1 n
O I am a sole proprietor and have no one «vorking for me-
I am a home owner perfonuing all the work myself.
NOTr:plc be Uc txxzr -r3 tro clay]r o s to d� of
rwt mo(t tt---tlm Ln?u in wb, the bo.,'rcaido a oa he pvl vi, z p cn tb o-x C-,.-::11,+0'c—& w b
eaLoloye-s ua^.c Lhe t.tz-t:dz --•!�co Au(GI-152-�1(5)},_ppbatiou Frf.bommuvcr fnr e Lc----,e«permil a y c ideooc tL,e
Icgil cz2nu of e c :plovx under dw Wocicoe.Co aalioa Apt
I undazzand Ct»a oon of thi.ahem su m y bo foe--_t d to tba D v—,nr,!of 1,�&s•.ricl A—dcoi Offioo of lr��for tlnc
oovcr-I Ct vuif cuioa&� tiu f_ltat to smut oovcrnZ�uI-'dC:r��0-0 2 S A of 1,(GL 157 can Iced to Lh,Lag>owfioza of cnm atl pca&itia
comzrmg of a ED<of up to S I X00.00 ezid/cx i of up to oz year LZA civil pmehio in dx form o(e Stop Work Order end a
firr of 5100.00.d_y tpio-a me
` F«dcp,ruz,�l ur_only --
/ —
MaP;; Lot
I-St "Llirt of LicciiscCAICrill cc � e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�sl �hi.. rp�rnil �tracfor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION:INSURANCE AFFIDAVIT(MG.L.c.162,§26C(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...... ❑
Al
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 buildine 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" ertifies rdas mes respo nsibility for compliance with the State Building Code,City of
Northampton Ordinances, tate a Loca g Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature 0.
r 04"
SECTION 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 D to f Prq�s�a �13 �y� CiICt�
work:a Off' �F �' 5 T7l p/�Cll�( W9 $
Alteration of existing bedroom Yes No Adding new bedroom Yes No 'r( L
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s l 1~w tiouf n+ >I add ioll v zi iir 0 hour n � i t4fe tJ aw�ncl:
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
I, Om � ��('r1�G{ as Owner of the subject
properly
hereb authorize 14 U��OPW
to o my beh in all matters relative to work authorized by this building permit a plication.
Sigrfature 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 penalties of perjury.
NIL [Me4
Print me
J.'L
Signat re of Owner/Ag nt IT 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
, 1
Frontage
Setbacks Front v1-'f-
Side L: R:?"Te L:L�R:_ "i
Rear zo� U
Building Height ?1 ( 1
Bldg. Square Footage (Q tJ 56) zid %
(J 7V r
Open Space Footage 5410 ( % 5410 t
(Lot area minus bldg&paved i
parking)�i
#of Parking Spaces - `
Fill: O
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW OC YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW C YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO _ DONT 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 X
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:
of Northampton
ing Department
JUN 1 3 � 2 Main Street
Room 100
DEPT Of BUII ort mpon,h t MA 01060 u
QING INSPECTIONS
NORTHAMPTON,hpbltil0W413-5 -1240 Fax 413-587-1272
APPLICATION 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
Map.. Lot Unit /
�A
A Z:on "Overlay Dlstrlp
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e int) allipa Address:
Telephone
Si nature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building °00 (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 Section For Official Use Only
Building Permit Number: 'D ` Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-1051
APPLICANT/CONTACT PERSON FROTHINGHAM PETER
ADDRESS/PHONE 131A STATE ST (413)585-5910()
PROPERTY LOCATION 131A STATE ST
MAP 31B PARCEL 147 ZONE URC
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: CONSTRUCT ROOF&SCREENS TO PART OF DECK OF ACCESSORY APARTMENT
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 f�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
THE
as presentedibased 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 Conservatio mmission Permit from CB Architecture Committee
oe
Signature of Building Official to
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.
t35 `ITET BP-2001-1051
GIs#: ? COMMONWEALTH OF MASSACHUSETTS
:31B- 141 CITY OF NORTHAMPTON
Lot:-004
Permit: Building
Category:Nonstructural interior renovations BUILDING PERMIT
Permit# BP-2001-1051
Project# JS-2001-1863
Est.Cost: $950.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor. License:
Use Group:
Lot Size(sq. ft.): Owner: FROTHINGHAM PETER
Zoning.URC Applicant. FROTHINGHAM PETER
AT.• 131 A STATE ST
Applicant Address: Phone: Insurance:
131A STATE ST (413) 585-5910 (�
NORTHAMPTONMA01060 ISSUED ON.•61141010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ROOF & SCREENS TO PART OF
DECK OF ACCESSORY APARTMENT
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 6/14/010:00:00 1117 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
_ __
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131A STATE ST BP-2001-1051
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Biock: 3113- 147 CITY OF NORTHAMPTON
Lot:-004
Permit: Building
•Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-1051
Proiect# JS-2001-1863
Est.Cost:$950.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.fr.): Owner: FRO ffl1Nv14AM PE't'17-R
zoning:URC Applicant: FROTHINGHAM PETER
AT: 131 A STATE ST
A_ pplicant Address: Phone: Insurance:
131A STATE ST (413)585-5910 (�
NORTHAMPTO.NMA01060 ISSUED ON:61141010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ROOF WNBWS TO PART OF
DECK OF ACCESSORY APARTMENT
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:
tas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0 KC
THIS PERMIT MAY BE REVOKED BY TH/CITY F NORTHAMPTON'UPON VIOLATI OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/14/010:00:00 1117 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo