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DEPARTMENT OP DUILDfNIG INSP-CTIot,S
212 Main Street ' Muoicipal Building
Northampton, Mass. 01060
WORICER'S CO\'[PENSATION CNSURANCF A1.1-[DAVIT
(llccusuJpcnnittcc) --
v,ith 2 principal place of businesslresidenee at.
(SU�t/city/S'ac-I gip)
do hereby cerdi ,-, under tllc pens and penalties of perjury, ?hat
( ) I an an employer providin- the iollowint-, workers comoens-�ion cove:ale for Inv
eluplovices wori311g on tills job.
(La-g== COo=Y) (Petit; Nu--,ib--r)
I am a sole proprietor, general contractor or omeowver citcie one) and have hired
e contractors listed below who have the follo%ving worrier's co=�)en--,,-tion policies:
(l+Q nc of COi!'::1Cio-) (I(1$Lrai1C: Colnpan}'(t�GllCt ��Ulll!'<T) (i'.?:DliiluQi! 1111C)
(Name of Contractor) (l1LS'r1TanCC COmDanN'/PoI.ic)' Nlltncsr) (—Expir,:iion Date)
(Name 01Conrracto,) Q-nsuranc Compan)•/Pot�cy Numb l) (E\piroon Date)
(fame of Contractor) (Iasuranu� Company/Pol cy Numbs) (Expiration Datc)
ilnccc,ry to infor z n. pcztn.=g to.11
( ) I am a sole proprietor and have no one woriang for me.
( ) I am.a home owner performing all the work myseff.
NOTE:plc..sc be a Yirc tti.•k{ ]c`h�-ca—r��._o-u'—J"ut,employ per,o to l cC c rc uu ork ou.d..cll- Z of
an(n)c,-tb�t�rr Li'j in why the M I,aid0 or o0 lbz VOl134J 1"p:rtCnarl lbcGo LT not ccaa 2 ty oe=i&rrd to be
catploy—Uoe—the cc=pCnn�mfim Act(GL152 Q 1(5)�appdca600 by a bomcoo-cr fnr c U.cz:==a permn r>;-.y—dc tbc
Icga1 rtsnu of an oxployx under dw Worked,Comgom.lio x Act
I undaitw d th,a a copy of thi,rtat.em�w m.y bo forty—i.ed to rho pcq„rtmeat of Indurriel Arodec&Offioo of burr—for tbe
covcr-►Sc va-,GCElioo r+M that f_iluxt to scout`co%MTMa&a under Soaio¢23A of?,(GL 152 an Irmd to the l ion of ai niatl pcaehio
ooa&Lai of►ftoc of up to S I}00.00 and/or of up to Oo yrar and civil pcn.t'uo in(`.r form of a Stop Work Ordc and a
rim of S t .00 S day■punA me h
V l.�Cs For dcp.rtm--J Drily
e Permit Number c-r
-I ° 1• ap",_ Lot
tgnatu -of Li rrnittcc � e
SECTION 8,-CONSTRUCTION SERVICES!
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
N t
, .
o pp is
- �.. �.,�,E.., .� A I' able ❑
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...... ❑
p
W,,
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"ce i lies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, S e d Local Zoning Las d StatS f M sachusetts General Laws Annotated.
✓Homeowner Signature c
ow
AECTIbN 5-`D959911ETIMPE; P P Q$FQ WORK(rbeck all is I
New House 13 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No ,[
Attached Narrative❑ Renovating unfinished basement Yes o
Plans Attached Roll ❑ - Sheet❑
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 BECOMPLETED WHEN
OWNERS AGI;NTOR CONTRACTOR APPLIt FOR BUILDING PERMIT
I, , 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
I, 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 e %
-.-,/ V�Adt'z-'
Signature of Owner A e 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
1
Lot Size
Frontage
Setbacks Front
Side L: R: L: R: (D
r
Rear
Building Height C;16
Bldg. Square Footage /d 0--') % 6 -�
Open Space Footage %
(Lot area minus bldg&paved i7
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 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 #
r
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:
` k
City Mpartment
hampton
OCT 5 20�uilditi
4 212 Main Street
OF .:. I:Room 100
:DLO atnp#on, MA 01060
phone 413-587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prooertv Address:
z y
m�ss Zone ��►#rf�
E(n�, t bst�ict. >, S1rYci
SE ION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
64t q
Name(Print) Current ffg Address:
Telephone
Signature �(
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
complete complete4 by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical K (b) Estimated Total Cast 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: O Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0360
APPLICANT/CONTACT PERSON LEVAY BRADLEY J&CAROLYN J
ADDRESS/PHONE 5 HEFFERNAN ST (413)584-2162 Q
PROPERTY LOCATION 5 HEFFERNAN ST
MAP I 1 C PARCEL 021 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out A 24
Fee Paid a 61 - —
Typeof Construction: ERECT 8 X 12 SHED
New Construction
Non Structural interior renovations
_ Addition to Existing - —
Accessory Structure –
Building Plans Included•
Owner/Statement or License
3 sets of 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 Conservat' Commission Permit from CB Architecture Committee
D �
Signature of Buildja Build' 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.
5 HEFFERNAN ST BP-2001-0360
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I IC-021 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category shed BUILDING PERMIT
Permit# BP-2001-0360
Project# JS-2001-0585
Est. Cost:$2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group:
Lot Size(sq. ft.): 8494.20 Owner: LEVAY BRADLEY J&CAROLYN J
Zoning:URA Applicant: LEVAY BRADLEY J & CAROLYN J
AT. 5 HEFFERNAN ST
Applicant Address: Phone: Insurance:
5 HEFFERNAN ST (413) 584-2162 0
LEEDSMA01053 ISSUED ON.10 16100 0:00:00
TO PERFORM THE FOLLOWING WORK:ER E CT 8 X 12 S ED
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 10/6/00 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo