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U DEPARTME1JT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
?Northampton, Mass. 01060
WORKS, R'S COMTENSATION tNSURA_NCF AFF DANTZT
(li ccusc:Jpc�rni ttcc)
%Vith a principal place of businesslresidence at
-- �? �' 1C -- t4�_2 . �► [9MxU66Vq
(stmt/city/staicfz�p)
do hereby certify, under the pains and penalties of penury, that
( I am an employer providui- the following worker's compensanon cove mge for my
employceS worming on tills job
-7 3 I �j -
(Ia=n Ccezp_,sy) (Polio: Nu_ntbcr) (-,piration Date)
(,/ >_lam a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the 'MoWug worker's compensation policies:
(Name of Co:;��--,Ictor) (In�ranc Comnan �ouc, .'um>Y;) am1u0n Date)
}
�1►nA ax Z-`)), -6,
L gT1,j Li r� ?
(Name of Contractor) (Instrancc Company/Tolicy Num--r) (LxDUZiIon Date)
(Name of Coarl-actor) Gnsw-anc: Compu)./Poke} Nuirber) (Expimiio❑ Date)
(Name of Contractor) (Insurance Comps /Pol cy Number) (Expiration Date)
(a aach additi oml thcd if nccazu}to induc+*i fS mi:oc pcxtnining to all coa rn c o )
( ) I am a sole propietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:pl=-e be awuzc thzt wLjo homscwcr,.i>o employ pc som to 60 M R31 ccaue loo Cr rtparr work ou e d«eil g of
not tnoee than tbrco units m which tf).c boax mcr raid,, c oa the Qoun,�i appurtenant thcct arc ooe gcocrnlly ooardcrcd to be
cziploy 3 under the wo ts's c0mpcasz1icn Act(GL152ss 1(5)�application by a homeoavcr far a liecnx a permit msy-,rd--the
legal at tau of an cmployoc under tho Worked g Compocn&Ljon Ad
I undersitnd th.i a copy of this rtxL—o aml any Lo focwnrdnd to tho Dc�ml of ln�s-xri el Avad=iy Offioo of I�for tlm
covcr�gc va-L6astioc and that Liltuc to scatrc covc�under suction 25 A of MOL 152 can lad to tbo imposifioc of cnminsl pcnaitia
coasisting of a fine of up to S 1,500.00 and/or impruovnxal of up to orx year end anal p cum in the form of a Stop Work Order and e
fim of S100.00•day rgainA t>x
For dcp rtmm'S ui drily
2z(b L_- PCi lI 11 Number —
_. ivUP, Lot
Signahirc of LicaisccJPcrmittce a e
SECTION.8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ZA-1
License Number
-----------------------
. 4
Address Expiration Date
- ----------------
Signature Telephone
......... Not Applicable
. ..
-7 0
647--------
-
------------------ -------I-
Registration Number
Company Name ------------------------------
Address Expiration Date
t-D 0
---- _11?Tb0r-3 VVY-\----------Telephone—
I
SECTION. 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.�C. 1152j§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...... ❑
1.000-cf: Exemption
to
............
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 lie/she shall be
responsible for all such work performed tinder the buildint!Permit.
As acting Construction Supervisor your presence on the job site will be required from tune to tine,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 pennit.
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
M � '
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[ J
Brief Description of Proposed
Work: - Q-0 0V ^
Alteration of existing bedroom---_--_Yes-_____ No Adding new bedroom_ Yes _______ No
Attached Narrative Renovating unfinished basement -------Yes _
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-i OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ____ ----_-___---_,as Owner of the subject
property
hereby authorize _________
to act on my half,Ji�n�all smatters r ative to work a thorized by this building permit application.
----- -!!�! �J! -- ------------------------------------
Signature of O. ner Date
VA� q �_� 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 unde he pains and penalties of perjury.
---- --------------- -- ------------------------- --------------------
Print Name
--- ------------- ----- =--------------------- ?� -t' ---------------------------
Signature of Owner/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 col in to be filled in by
Build' Department
Lot Size
Frontage
Setbacks Front
Side L: R: L R:
Rear �v
Building Height �f
Bldg. Square Footage %
P
Open Space Footage %
(Lot area minus bldg&
parking)
#of Parkin paces
F'
f,.
'volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:_____
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW _ YES _
IF YES: enter Book _ Page________ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO _ 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:
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Northam ton, MA 01060 � b>qtr;Ufa...........................:.r--�.-r.—.........—,... ... .
- 87-1272
Fax 413 5
.R�Qne 413- 87 1 40
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PTIG'AfION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
MR.a A.
1.1 Property Address: This set♦kion f�ba co bV+o': i
t-���*S `�T-
Map., 1»vt M.,.iJnat
Zone _ Ovarly i3Istr `_ _
AA
N�
EIrri St Dft.16t :. �..: CB)it#tYi t
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -�
---, ,,�-------------- --------------------- ---------L�--try-'--�---�� ��
Name*Pin Current Mailing Address:– –�! ----- ------- Telephone
Signat
2.2 Authorized Agent:
, R1 -----L�.e'►+' i�1�—i UR_ -----�— ---�v 2------�—� ---
Name(Print) Current Mailing Address:
), 1 2 Z IL
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be ; Official Use Oriiy
completed by ermit applicant
1. Building /_ �� (a)B.did.i.h.g Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Pertrit Fea
2j� tjts.
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) . Check Number
This Section For Official Use Onl
Date
Building Permit Number. _ w .___M_ __.__.__ Issued:
Signature: ------------- --- ---- ----'- -- ^—
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0790
APPLICANT/CONTACT PERSON Robert Walker
ADDRESS/PHONE 36 Service Center (413) 584-1224
PROPERTY LOCATION 16 HOWES ST
MAP 17A PARCEL 169 001 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 7211 X5V
Typeof Construction: REMODEL 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 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 Co sion
Signature of Building Official Dat
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.
16 HOWES ST
GIS#;
M- $lock: 17A- 169 COMMONWEALTH BP-2002-0790
Lot CITY OF �F MASSACHUSETTS
Permit. NORTHAMPT
Buildin ON
Cate or :Non strut
fora'interior renovations BVILDING!t# BP 2002 0790 PERNUT
Prto ect# JS 2002 1318
Est. Cost• 9440 00
FeeFee--$50.00
Cons tclass; PERMISSION IS HEREgy
Usee Gr_ouup. Contractor: GRANTED To:
Lot Sizes .ft. : 8537 76 Robert Walker License:
zoni— RB Owner: DRESL'NSRiSTAN& 034783
A licant: Robert Walker
ApplicantAddress: '4�'• 16 NOVVES ST
36 Service Center
Com ensation Phone:
413 584-1224 Insu--=gaet:
NORTHAMPTONMA01060 Workers
TO PERFOR�yj THE FOLLOWING •3i2-!2- 0.0 0:00
WORK,REMODEL BATHROOM
POST THIS CARD SO IT IS VISIBLE FROM TH E STREE T
Inspector of Plumbing Inspector of Wiring D.P.W.
Underground:
Service: Building Inspector
Rough:J7�a� Meter:
Rough: 2, 16 L �,,, Footings:
&00 House#
FinalDriveway Final: Foundation:
� Final:
Gas:
Rough Frame:
Fire Depa�ent
Rough: Fireplace/Chimney:
Final: IP-stz,+atieaa:
S- e:
Final: Q
THIS PERMIT MAYBE � r` -1 2 -dO�_'`
ANY OF ITS RULES AND REVOKED BY THE CITY OF NORTHAMPTON
REGULATIONS, UPON VIOLATION OF
Certificate of Occu ant `;� ___Z�• �.y,,,,.
Fee T e;
Recei 3t No; Si nature:
Date Paid:
Building Check No: Amount:
3121102 0:00:00
1110
$50.00
212 Main Street,Phone(413)587-1240,Fax;
Building Commissioner- (413)587-1272
Anthony Patitlo