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209 eac"ir Stzeat, Toz 60142
57e"ewee, Va". 01062
413 586-9491 • 57,1x: 582-0275
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euata weeecoaa • �7e.ce eaifekea
209 Zaeuat Street, Tat 60142
76aze.cee, 1J6aaa. 01062
413 586-8491 • 7,4x: 582-0275
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORICER'S COMPENSATION INSURANCE AFFAI[DAVTT
picenserlpermittce}
with a principal place of business/residence at:
(phone#) (�
(stm--t/ci ty/stalchip)
do hereby certify, under the pains and penalties of penury, that:
O I am an employer providing the following worker's compensation coverage for my
employees worcing on this jab:
(Insurance Company) (PoLic�Number) (Expiration Daze)
( ) 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 Number) (Expiration Date)
r
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inswan(-- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioaal sbcet if noocvuy to inc]udc information pertaining to all ccatracton)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcoitvcra wbo employ pGZam to do mai..�o=strucuoo cr rtpair work on a dwelling of
not morn than threo units in which the homoowvcr resides or on the grounds appurtenant tha-ao arc oot generally co¢siducd to be
cmploycrs and cr the worker's.aanpaasatioa Act(GL152,ss 1(5)�application by a hom00%-=for a li—a permit may evidmoc the
]cgal data of an amployor under tho Workees Compensation Acc
1 unae stand that a copy of this rtatcmccd may be forwnrdad to tho Dcgwtzn�of lodustrial Acci& &Offi o of Imru.00a for tho
oovcrrtgC verification and that failure to sm=oovemgo tinder scetioa 25A of MGL 152 can lead to tbo imposition of aimhW penalties
g of a fitx of up to S 1,300.00 anNee imprisoameal of up to cm year and civil pcnatlia in the form of a Stop Work Ord and a
firm a(5100.00 a day against mr–
/ f For dcpzrtmmW u xo only
1 . , permit Nwnber
Map;l Lot
,�,. Si f Li ttce e
SECTION 8 ,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 4-f 1)�? 4570
License Number
Address Exp6ratid Date
sigr&6e Telephone
Re ed -. m.e. p em'ntCon ractor _„ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'.CAMPENSATION 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 f the building permit.
Signed Affidavit Attached Yes....... No...... ❑
n
.. emF .n:
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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition [ Replacement Windows Alteration(s) El Roofing 111
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: (� � 1 1142 XIV -
Alteration of existing bedroom Yes —V/ No Adding new bedroom Yes V No
Attached Narrative 0 Renovating unfinished basement _Yes No
Plans Attached Roll ❑ - Sheet ❑
6a.af News''hoiise antl or.atltlition o existin ' bdu'sin com leteahe fo'Ilowin° :
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?V/ 0
d. Proposed Square footage of new construction._/' � Dimensions -•t r���
e. Number of stories? I
f. Method of heating? Uee'. Fireplaces or Woodstoves—d--_ Number of each
g. Energy Conservation Compliance. __ Mascheck Energy Compliance form attached?— AF16
In. Type of construction 111ki'. UCCA M"L .
No. Is construction within 100 r. floodplain Yes _ No
i. Is construction within 100 ft. of wetlands. Yes � Y
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building nd Zoning regulations? Yes
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
as Owner of the subject property
hereby auth _--to act on
my beh .I , in all at ative to work authorized by this building permit application.
4
Signature of Owner Date L
�� -- as Owner/Authorized Agent
hereby dec re 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.
1-41")z
Print Name
Date
signature of Owner/ g
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 j / (/'
Fronta e
Setbacks Front
Side L: � � R: L: i t,`' R:
Rear
Building Height l•
Bldg. Square Footage "'C�� % `V
Open Space Footage % `
(Lot area minus bldg&paved
parking)f
� L
#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 ermit 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 ns exist on the property? YES NO
IF YES, describe size, type and location:
D. Are here any proposed changes to or additions of signs intended for the property?YES
No
U`, IFYES, describe size, type and location:
City of Northampton S
Building Department CUrbGuq«
212 Main Street Se er S I.
Room 100 4Ya ertWe
Northampton, MA 01060
phone 413-587-1240 Fax 413.587-1272 I?R 'YSl e P in A n
Oter�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
*,
r
Map Lot � Utt
Zone laysDistrict F
Elm St. District CB District „
SECTION 2 PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
L( Sj:n _aac GLyid 173 Q 14 1 e4 6
T(Print)) l Current Mailin4 Add S.
Telephone
Signature
2.2 Authorized Agent: Q�lJ✓off
Name(Pri ) Current Mailing Address:
qi3-d9,1-•Y6U 1
Sign r 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. Elecirica! (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) 1 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature;'
Building,Commissioner/inspector of Buildings Dater
File#BP-2003-0564
APPLICANT/CONTACT PERSON HAYES DALTON D_ 71 dtv V-
ADDRESS/PHONE 129 SOUTH ST (413) 582-0445
PROPERTY LOCATION 132 HIGH ST
MAP 17C PARCEL 141 001 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 5 OUT-
Typeof Construction: CONSTRUCT 12 X A SUNROOM
New Construction /V% l�
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 074570
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 Office of
Planning&Development for more information.
File#BP-2003-0564 r -
APPLICANT/CONTACT H
ADDRESS/PHONE 129 SOUTH ST (4 3)582- 04445
PROPERTY LOCATION 132 HIGH ST
MAP 17C PARCEL 141 001 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 14 X 10 SUNROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074570
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Commission
Signature of Buildin f vial D e
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.
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Hayes ba2t cep Permit for 132
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