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m DEPARTMENT OP BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSA'T'ION INSURANCE ATTIDAVIT
(Ii ceuserJpermi ttec)
with a principal place of business/residence at:
(phone#)
(stTMUCi ty/state12i P)
do hereby certify, under the pains and penalties of pegury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Numbcr) (Expiration Date)
f
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Lasuraace Comp=y/Policy Nunbe.r) (Expiration Date)
(attach additional shcct ifnto nu to inchxle iaforrnation pertaiuirg to ell
O I am a sole proprietor and have no one working for me.
I-Ir am a home owner performing all the work myself.
NOTE:ptcase be awazc thzt whilc homcowacrs who czplay pc,:z to do mAiracntac,'- cr rcpau wwo on a dwelling of
not moea than thrro units in wfmch the hanrouvcr rcsi&3 or oa the Vvu�apF�thccto ur rxX E;ra ly oc-micknd to be
anploycn ua.icr the worker's comp .sation Act(GLi52,s3 1(5)),application by a homcow=for a U=L-e o<permit may cvtdcnee the
leg l ctaau of an employer under the Woriccet Compco3ation AcL
I uadait nd thzt a.copy of this ctntcmmi may be forwarded to tbo Department of Iodzuiriel A—&-&Offioo of Lm—for the
coverage verification aad that failure to seatre coverago under scc ica 25A of MGL 152 can lead to tba impositioa of cruniail Pena'Ecs
- of a fine of up to S1,500.00 and/or caprisonmad of tip to one year and civil pcaaltia in the form of a Stop Work Ord--and a
firm of S 100.00 a day tgaiml me
For dcg:rtnrs r+1 a/O only
permit Number
--1 - WP4 Lot 4
k Slgnalure of Liccns /pertnitfee 3�e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company 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....... ❑ No...... ❑
11 WmeO�vner Ex mpt>�onn
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 o€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
SECTION 5- DESCRIPTION OF PROPOSED WORK(checkall applicable)
New House ❑ Addition ❑ Replacer nt Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other]
l
Brief Description of Proposed Work: ? 6.^ Ct-� i a ST6^�ia i*c 4AS C, t,(( ro0'(t,
Alteration of existing bedroom Yes < No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes > No
Plans Attached Roll 0 - Sheet❑
6a-"lf"N6 tfd se 6 d or'addition to`dxi§ting ho)Using' c6mp16te the 61'1b h*
a. Use of building : On iIv Two Family x Other
b. Number of rooms in each fami nit: b Number of Bathrooms
c. Is there a garage attached? _ AJ 50 New
°(
d. Proposed Square footage of new construction. Dimensions •J
e. Number of stories? 3
45 i
f. Method of heating? Wyk �'Q Qkc( 'c Firep s or Woodstoves jzyX_. Number of each
g. Energy Conservation Compliance. Mascheck ergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. o etlands? Yes No. Is construction ithin 100 yr. floodplain Yes __X-No
j. Depth of basement or ce r floor below finished grade
k. Will building confo to the Building and Zoning regulations? X 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
'GYd,vQ�Dr 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 penalties of perjury.
a&V', Gone
Print N e
Dat
��
Signature of Owner/Agent
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
Building Department
Lot Size
Frontage
Setbacks Front
, la6 rl<
,9
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Foota %
(Lot area minus bld paved
parking)
#of Ping 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 X YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO J\ 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:
t a
J21 Northampton s r
2 0 2042 g Department
MAY Main Streetoom 100pton, MA 01060 oSetsofi r c ra
phone 413-587-1240 Fax 413-587-1272 Plot/Site Pians� : - . . � � z
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section#o be completed by office
1.1 Property Address: , w" 2 N
/ a
Ma ' �t1n�t
Lot
6 p �
ZoneOver(ay District f s
No a r
Elm St. District CB.�Distnct. "
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i
Name(Print) Current My/1 Add ess; -,r7 S
� r� 5 Y t
s@txX 2 t4 L Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION C05TS'
Item Estimated Cost(Dollars)to be Official Use Only'
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical 3 00 (b) Estimated Total Cost of
Construction from 6'
3. Plumbing /c'QO , Building Permit Fee
4. Mechanical (HVAC
5. Fire Protection (G o .
6. Total =(1 + 2 + 3 + 4 + 5) 0 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-1010
APPLICANT/CONTACT PERSON O'CONNER COLLEEN
ADDRESS/PHONE 7-9 ORCHARD ST
PROPERTY LOCATION 7 ORCHARD ST
MAP 25C PARCEL 154 001 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 4 11 WCo 0
Typeof Construction: CREATE STUDIO/BEDROOM IN ATTIC,PLUS FULL BATH
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 BASED ON
INF ATION 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 ssion
O Zc�
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.
BP 2002 1010
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2002-1010
Project# JS-2002-1647
Est.Cost: $4300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 9016.92 Owner: O'CONNOR COLLEEN
Zoning.URB Applicant: O'CONNER COLLEEN
AT. 7 ORCHARD ST
Applicant Address: Phone: Insurance:
7-9 ORCHARD ST
NORTHAMPTON MAO 1060 ISSUED ON:614102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CREATE STUDIO/BEDROOM IN ATTIC, PLUS
FULL BATH (MUST UPDATE EXISTING SMOKES)
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 signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/4/02 0:00:00 1126 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
My intention is to create more living space in the third floor attic. I want to put a 22-34 foot
dormer with three or four windows on the south side of the house. The demensions of this
will depend on the advice of the builder and the limitations of the space and structure. But
this is my intent. I intend to put in a bathroom up there too. This, eventually will be an
extension of the second floor apartment which I wish to live in when my tenants move out in
the futu re. I am currently living in the first floor apartment.
V G,N it 0 V-
10. Do any signs exist on the property? YES NO
IF YES, describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property,?YES NO
IF YES,describe size,type and location:
11 ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE 1�:)
LAC' OF INFORMATION.
TL,i.9 column to b� 2i'1-1
by the Ralld g
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
--------
Building -------
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&Paved park-L-2 g I N
# of -Parking spaces
# of Loading Docks
Fill:
vol-ume -& location)
13 . Certification: I hereby certify that the information contained h e i e 1'
is true and accurate to the best of my knowledge .
DATE: APPLICANTs SIGNATURE
NOTE: lanuinnoe- of as zoning permit does not relieve an applioanta burden to comply witty'ali
zoning requirements and obtain all required permits from the Board of Health, Conserveitio,
Comminalon, Department of Public Work= and other applicable permit granting authorities.
FILE
-
No'
` ��� �� � �
PERMIT ~~~ P~�I��^TI=^, x �r�� ^ ��
L~~�
PLEASE =E OR I=T ALL INFORMATION
y�
1. Name of Applicant:
Address:
2. Owner ofPropedy:
Address: —Telephone-,--f`°-^-�
3. Status ufApplicant: _�^'�_Ovvnar Contract Purchaser_____Lessee
Other(explain):
4 Job Location:
Parcel |d: Zoning Map Poroe| District(s):-
(TO BE FILLED |N8Y THE BUILDING DEPARTWENT) �---
6 Existing Use ofStruoture/Propedy
5. Description o/Proposed Uae/VVork9Pro)eot/Occupabon: (Use addituna| sheets-ifnaoeosory):
7. Attached Plans: Sketch Plan Site Plan Engineerad/Sun/eyedP|uns
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8 Has a Special PernniUVahanue/Finding ever been issued for/on the site?
N{} DON'T KNO YES |FYES. da�aisuod:
________ `_______
IF YES: Was the permit recorded at the Registry o/Deeds?
NO DON'T KNO YES
�
IF YES: enter Book Page_______ and/or Documeot#___
S. Does the site contain a brook, body of water orwetlands? N DON'T KNOVV YE
|FlyEG. haaopnrmkbeenurnoedtobeobtainedfromtbeCunaowotionCommisuion?
Needs tobo obtained Obtaine .doteionued:
(FORM CONTINUES ON OTHER SIDE)
File#MP-2002-0104
APPLICANT/CONTACT PERSON O'CONNOR COLLEEN ���w
ADDRESS/PHONE 7 ORCHARD ST (413)587-9775 Q or✓ ��
THIS SECTION FOR OFFICIAL USE ONLY �+
PERMIT APPLICATION CHECKLIST
ENCLOSED R]
=ZONING LS OUT d out
Fee Paid
Tvpeof Construction: ZPA-EXTEND 2ND FLR APARTMENT TO ATTIC
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
INFORMATION 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 Commission
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 the Office of
Planning&Development for more information.
67YAr'pz, PZA
7 ORCHARD ST BP-2002-1010
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 154 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1010
Project# JS-2002-1647
Est. Cost: $4300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg.ft.): 9016.92 Owner: O'CONNOR COLLEEN
Zgnin :URB 4nniirpnt: O'CONNER COI-I_F_EN
AT. 7 ORCHARD ST
Applicant Address: Phone: Insurance:
7-9 ORCHARD ST
NORTHAMPTON MAO 1060 ISSUED ON.614102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CREATE STUDIO/BEDROOM IN ATTIC, PLUS
FULL BATH (MUST UPDATE EXISTING SMOKES)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: AIMS z AW; Meter:
Footings:
Rough: Rough: /�Iv.� House# Foundation:
Driveway Final:
Final:O y-t,,�L Final: JJJ(ti tG�/ fj��/f�ltGektl
/�� Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: .'V/-1- Insulation:
Final: Smoke: yi / y�3y 3 Final:Q jr
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ryw �r /
Si nature:
Certificate of Occupancy—
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/4/02 0:00:00 1126 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo