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DEPARTMENT OF BUILDING INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 0106d
WORIQIR'S COMPENSATION INSURANCE A { AVTT
(li ccnscx/perm i ttcc) — -
with a principal place of businesslresidence at:
�-
(stretit/ci h/staLJ�p)
do hereby cei tify, under the pains <,-nd penalties of perjury, thra
( I am an employer providing the following worker's compensation coverage for my
employees worming on tl>is job:
C �'1•'� 1 t��l � e �.'� b L
(Insu.rance Company) (Polio✓Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeoNvner (circle one) and have hired
the contractors listed below who have the foiloVw-ing worker's compensation policies:
�It>nte of Cont.acto;i in�urtnc� �:or,; ��;;,;rolic� 'uilibc;; (L -a
Date)
(N,.me of Contractor) (Insurance Conit u: ,-folln, (Expmatncn Date)
------- -- — ---------
(Name of Contrtctor) jrtsuran, Date!
(Name of Contractor) (Insuranc; Compa-<lyiPolicy Number) (Expiration Date)
(atiaeh additioi d sheet i_f no—-indud<iaformation pertaining•y all o radon)
( ) I am a sole proprietor and have no one working for me
O I am a home owner perfonning all the work myself.
NOTE:please be aware that ytihile homeowner,'Abo rnpl ay w cio nlauricaaii-�, cr r-cpac Puri:<nt a d,�Ilmg c:
not more than throe units in wh cfi the honnounQ mid=or oc the P--cu:ths appcutcnarA thtm-- ..2 not 1,-ctxr211y oomicicmi to tx
cWloyrrs under the wo leer`s cecnpesrsatim Act(GL152sa 1(5)),afTG-)on try a hotncowncr fore h"CIMx oc permit niav aIdcacx the
legal ctnnre of an oMVlova under tho woektKr a Conq�tio<i Act_
i undtrstand that a cm,y of this ctatc -ct may bo forw'iv led to tlx of lnd xric A udrnLf Ofrioo of(ruua for tfm
covcagc va-ifrcatioo aad that fail rrc to&CCUrt oovcragC ur der socti r:25A of h40L 152 can Icad to tttc imposition of cr urinal pcnalii=
cocmuting of a fine of up to S1,500,00 ar0cx-FITIrnsonnc--z;of up to oix}w arA aril peralnn if;ttr f<xnt of a Stop wmi O-d'!T and a
fine of S 100.0()a dsy a-w umt[tr-
Fu cigwVTr_Cnl uac only
le, ` M<tn;i I.ot
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
Supervisor: Not Applicable ❑
Name of License Holder: er -, 6&(U-A LA— \(-y-Cg Q
` 7 �-,°
License Number
Chi(�' 'i ( c-, ( ( ' 2 c�C>-
Address Expiration Date
Signature Telephone
9' Reclistered'Home Improvement Contractor: Not Applicable ❑
Company Name I Registration Number
2 V1
Address Expiration Date
Telephone C
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. - Home Owner Exemption
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
r
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 Description of Proposed i
Work:
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll L-Sh eet
6a. If New house and or addition to existing housing, complete the following:
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, � ► k i� AAA (}(2 �1 �1`t�-ti`��� as Owner of the subject
property
hereby authorize
to act on my behalf, in 41 matters relative to work authorized by this building permit application.
SI`gKat0fe 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.
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATI0N MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OI+ INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size CA �i V
Frontage
Setbacks Front dO
side L: I L _R: 2?_-7 L: 1 (,9R:_ 2-7 15-
Rear
� v
Building Height ft
Bldg. Square Footage V C� 1 % CC U ! 2,
Open Space Footage V�
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special rmit/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 1' 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
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:___ _ ___
Department use only
City of Northampton Status of Permit:
Building Department CurbCut/DrluewayPermit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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
C�
Map � Lot `' 6;� Unit
` Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: �Mt�� �-1 IT—
Telephone c cJ
Signature
2.2 Authorized A ent:
(�W-� (,�..A�� r�(- slz fu VX I ry
Name(Prin Current Mailing Address:
Cr2 C7 J -Z 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 v (b) st u
Estimated Total Cosa of
3. Plumbing r 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: //p'�3 Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Hr ] u Lu3
File#BP-2003-0871
APPLICANT/CONTACT PERSON Robert Walker
ADDRESS/PHONE 36 Service Center (413)584-1224
PROPERTY LOCATION 122 CHESTNUT ST
MAP 17C PARCEL 092 001 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
Typeof Construction: CONSTRUCT IfEAR 6'X 9' 1 ST FLR BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 034783
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO AATION 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 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 Office of
Planning&Development for more information.
122 CHES7.N,,. BP-2003-0871
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-092 CITY OF NORTHAMPTON
Lot: -001
Permit: Buiidim
Category BUILDING PERMIT
Permit# BP-2003-0871
Project# ]S-2003-1410
Est.Cost: $14400.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Walker 034783
Lot Size(sq. ft.): 7013.16 Owner: MAYESKI MAUREEN F
zoning.URB Applicant: Robert Walker
AT. 122 CHESTNUT ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-1224 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:4123103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT REAR 6' X 9' 1ST FLR BATHROOM
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: � �'1�Rough: House# Foundation:
Driveway Final:
Final:� � Final: ( J��j (9)
A r Rough Frame:0x 5'697.03 `t4v
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: d K (p 7•Q 3—4
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AN72;;i;;97Si2nature:
Certificate of Occupancy
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/23/03 0:00:00 1152 $50.00
212 Main Street,Phoiie(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo