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a a f�assarf(nsrtla
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
, o
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMA AVIT
1,
(licenserJpermittec) -
with a principal place of business/residence at-.
(phone#)
(str-eet/city/stafr/zi p)
do hereby certify, under the pains and penalties of peouly, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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)
,,
(Name of Contractor) (I.nsurance Compai y/Poticy Number) (Expiration Date)
(Name of Contractor) (Iasw-ance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Comparty/Policy Number) (Expiration Date)
(atlach additional sheet ifnoccxsi to include information patnining to all ooctrn 13)
( ) 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 while hOMCOwDCr3 who crnplay perIa=u do trza�=Istr co or repair work on a dwelling of
not azoce than tiv>;o units in which the lwnxovvncr resides a oa the grounds appuctermnt thereto arz Dot generally eocsidcrcd to be
employes under tho workers ration Act(GL152,ss l(5)),application by a homcovma fora leerier a permit may cvidcnoo the
legal status of an omployec under tho Worfcods Compensation Ace.
I undaatand that a Dopy of this szatcmcai may bo fo:warcied to tho Department of Indauh ial Mcidcat�Ofboc of kvAu moo for the
coverxgv verificauoo and that failure to sealre covemV under section 25A of MGL 152 can lead to the imposition of criminal pcnali:ea
00asisting of a floe of up to S1,500.00 mrWor i nprisoatncat of up to one year and civil pcnattics in the form of a Stop Work Order and a
fins 0(5100.00 a day against tact.
For dcp:rtr�—only
permit Number
Map,{ Lot#
Silhtre of LicenseelPermitfee e 1
SECTION 8 CONSTRUCTION SERVICES
i
8.1 Licensed Construction Supervisor: Not Applicable ❑
j Name of License Holder
License Number
Address Expiration Date
Signature Telephone
I
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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...... ❑
W, F
IT
11 =. om . Ovine gemton'
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 pen-nit 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 pen-nit.
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' applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. X Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: STor e. 57" !i e
Alteration of existing bedroom Yes X No Adding new bedroom Yes X _ No
Attached Narrative❑ Renovating unfinished basement Yes X No
Plans Attached Roll ❑ - Sheet)K
6a lf`Newxl7o s"e ar d�oir tldition'to eXisting hous'in ,-completer he'4611' ihit
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
I
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-"OVYNER=AUTHORIZATION -TO BE COMPLETED WHEN
OYYNERSAGENI`ORCONTRACTOR APPLIES FOR BUILDING 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.
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.
Print Name
Signature of Owner/Agent y�— Date C oZ �'�
~ r
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 /60 160 cm 50 t7
Frontage Qrp !6 D
Setbacks Front
Side L: Sa R: L: S0 R: -�-o
Rear
Building Height
Bldg. Square Footage %
7? SQ
F
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces Z
Fill: N� N
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 #
B. Does the site contain a brook, body of water or wetlands? NO X 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 x
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:
City of Northampton
Building Department r
212 Main Street .
Room 100 a
Northampton, MA 01060 Two etso r, a--
phone 413-587-1240 Fax 413-587-1272 PiotlS.lte Pln — � �
Other Speclfy���� �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION.
This section to be completed by office
1.1 Property Address: r�
Map tot' � �� �� ' ,
� � --
,��a 7,r-p— Y�a 0106 Zone Distrtc
o
�F
Elm St. District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: AL/ a n�
n G 3 73 r b i ht Q —_
Name(Print) Current Mailing Addres :
_L!o t- a art r-c —
X Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address
I
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 (b) Estimated Total Cost of
n o y7 L Construction from 6
3. Plumbing Building Permit fee
'>7 a)7 e-
4. Mechanical (HVAC)
5. Fire Protection wj o
6. Total = (1 + 2 + 3 + 4 + 5) 100- ') o Check NumbL--4 --'
This Section For Official Use Only
Building.Permit Number: -Date Issued:
Signature:
Building Comm issioner/In5,pector of Buildings Date
File#BP-2002-0403
APPLICANT/CONTACT PERSON CHEEUNG KWONG KUEN&
ADDRESS/PHONE 373 BRIDGE RD (413)586-3246 Q
PROPERTY LOCATION 373 BRIDGE RD
MAP 17A PARCEL 133 001 ZONE URA
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: ERECT 9 X 11 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
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPFRMATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 C ission
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-2002-0403
GIS#: COMMONWEALTH OF MASSACHUSETTS
:Black 17A,-,133 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: shed BUILDING PERMIT
Permit# BP-2002-0403
Project# JS-2002-0619
Est.Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sa. ft.): 11151.36 Owner: CHEEUNG KWONG KUEN&
Zoning: URA Applicant: CHEEUNG KWONG KUEN &
AT. 373 BRIDGE RD
Applicant Address: Phone: Insurance:
373 BRIDGE RD (413) 586-3246 O
FLORENCEMA01062 ISSUED ON:10 118101 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 9 X 11 SHED
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 10/18/010:00:00 287 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo