32A-058 (12) MAR 7 2001
DEPT OF auit.oIN fNSPECTIO 132
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49 Main Sreet
Hatfie{d,Ma 01038-9702
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am subject to won an be mbasad or espied unlscc MEN AGNA
site and mowb wd:to fit jab appkable fee fns been paid-job
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKEWS COMPENSATTON INSURANCE AFFIDAVIT
(licensedpermittee)
with a principal place of business/residence at:
Ot668 (phone#) X13 7-4 ZZ6
(street/city/s &a dp)
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 working on this job:
1 It
(Insurance Company) (Policy Number) (Expiration Date)
i
I am a Ekid�beDlow general contractor or homeowner (circle one) and have hired
the contracto who have the following worker's compensation policies:
R -Jau w.b � 64�41t- s ZO v B `'l ff9 f o _ o
ame of Contractor) (Insurance Company/Policy Numbcr) (F.xprratio Date)
w O9e5fi I !e 2 m b K v 5 b y 3
(Name of Contractor) ( snc P
Company/Policy Number) (ExP u n Date)
(Name of Contractor) (Insurance Comparty/Policy Number) (Expiration Date)
�n)V�'� t DfKc . 71. C'ia g o�
(Name of Contractor) (Insurance Company/Policy Number) (Expiration ate)
Otiach additioml shed ifnecenary to iacluclo information peruining to all ooatrazt=)
O I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE'please be aware that vihilo homcownets who employ pc==to do maiatemance,cmsuuctioa or rqxtir work on a dwelling of
not more than throe units in wtrichthe homeowner resides or m the ground:appurtenant ihm do are not generany oomidered to be
employers under the arorkees comp=sation Ad(GL152,ss 1(5)1 application by a homewm r for a liaise or permit may evil—the
legal ctat, of an employer under the Worker's Compa satiom Ad.
I undettaad that a copy of this etatemeni may be forwarded to the DVutmcrd of Industrial A=&O&Office of Imwva ca for tba
coverage verification,and that failure to soatro coverage under seejoa 25A of MGL 152 can lad to the'imposition eaf criminal penalties
000&Ldng of a fine of up to$1,500.00 and/or impriso�of up to one year and civil penalties in the form of a stop Work Order and a
fine of 5100.00 a day against toe
For 1 use Only
d I Permit Number
Lot#
S of Licensee/Pernaitlee
EC7�ON,S-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: 1��A Not Applicable ❑
Name of License Bolder: yy lJ�'CT_1�7�1 C-s 0 ,55 9 t b
License Number
Address Expiration Ate
S' natur Telephone
iii , E E Not Applicable ❑
t w Z1- WOOLAQN-92 t
Company Name Registration Number
Address ,, (( Expiration ate
Telephone 4l J 2-47 OZZ6
SECT..ION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§250(0))
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...... ❑
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
VMKObak 911 1
New House ❑ Addition ❑ Replacement Windows Alteration(s)� Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: <N 54,V, 460}
Alteration of existing bedroom Yes XNo Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ - Sheet N
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
S CTI N 7a ,OWNER AUTHIORIZATION-10 BECOMPLE TED WHEN
'NERS AGtWT OR GONE I ACTQR AP:PU FOR 100t,0M,NG PERMIT
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.
"'� [11'0 y
Signature o Owner Da e
Ej r�lttttZ37c�1i�7.C, 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.
1�6M W�7�t
Print Nam
N-Z- 01
Signature o wner 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 X 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:
r .
f orthampton
` ' r Buil n Department
3 MAR 2001 2 in Street
0 100
mpt n, MA 01060
DEPT ot�^ j!i � Sir7.12 0 Fax 413-587.1272
Jq
NO
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.E
to l,-S11"E,Fb.I2MATIO
1.1 Property Address: �r � 7
F i1P fYah+?' ? 1k ,Y�,+`rk`7; �tY /# ,iry'd`Limzk. Fw797'x' �'X,r
xrc:Y �`` � �'x'•�, 7- ',. tai x.
SECTION Z-P1 PERTY,OW$ERSHfPIAUTHORIZED;.AG NT
2.1 Owner of Record:
t'\.��,�►��_ �O t//V/Dil,b c,��'• CpNCIO ��U /j1/lf'DiCf6
ame(Print) Current Mailing Address:
Tele�lyg _6 U 6 _Q6 09
Signature ``�y''��JJ U
2.2 Authorized Agent:
N rint) Current Mailing Address: Q l0,5 fj
q l �!) 2-4 7 - O ZZ-b
Si ature Telephone
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
b6S3�o0
2. Electrical o p (b) Estimated Total Cost of
r d
Construction from 6
3. Plumbing ��/ ,o� , 00 Building Permit Fee`
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 +3 +4+ 5)
Check,Numbe
This Section For Official Use Only
Building Permit Number, Issued:
Signature:
Building Commissioner/l,nspector of-Buildings. Oate
File#BP-2001-0713
APPLICANT/CONTACT PERSON JONATHAN BARDWELL
ADDRESS/PHONE 49 MAIN ST (413)247-0226
PROPERTY LOCATION 50 UNION ST-#10
MAP 32A PARCEL 058 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: REMODEL KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing -
Accessory Structure
Building Plans Included• -
Owner/Statement or License 055910
3 sets f Plans/Plot Plan
TH 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 Commiss* Permit from CB Architec a Committee
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.
50 UNION ST-#10 BP-2001-0713
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-058 CITY OF NORTHAMPTON
Lot: -010
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0713
Project# JS-2001-1338
Est.Cost: $10006.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use,Grouk: JONATHAN BARDWELL 055910
Lot Size(sq.ft.l_ Owner: MARANTZ THOMAS M&GWE14 AGNA
Zoning:URC Applicant: JONATHAN BARDWELL
AT: 50 UNION ST - #10
Applicant Address: Phone: Insurance:
49 MAIN ST (413) 247-0226
HATFIELDMA01038 ISSUED ON:317101 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN
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:�l/��Ql���� House# Foundation:
�Fina • C Final• 211' R-P'1J�
!! Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough; "__: ii►suiatior.:
Final: Smoke: Final: (j 14q
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/7/010:00:00 692 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo