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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE AFFIDAVIT
(Ii ceuserJpermi ttee}
with a principal place of busmesslresidence at:
(phone#)
(street/city/stair/ap)
do hereby certify, under the pains and penalties of pcgury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job.
(Insurance Company) (Policy Number) J (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/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Poticy Number) (Hxpiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiceasl srxci if ntc-zY to inc udc informatics pertaining to all c itraeion)
i
( ) I aln a sole proprietor and have no one worming for me.
I am a home owner performing all the work myself.
NOTE:please be aware that wiiilc homcotiTxn who crrzploy pczocu to do r_aiuirn �n ut os cr rcpaL work on a dµ'll&of
not moee than e n th units in which the r r,=dcs o<on tho grow s appurtenant tSccti a.- cw
c t GC 1Y cocsiticrcd to be
cmployas under the Work&S axi}xr_uticn Act(GL152--i 1(5)),nppUi bon by a homco%Nna for a 6c W'-a pcfala mmy"&Wc the
leg 2l status of an employor under tho Woricc+r'e Conap.L ion Ai.
I understand flat a copy of this etxtc wnt may be forwnidad to tbo Dtpartnxa2 of l.&L-,rial Ac6d,4Y Oflioo Of Ia-acrsnco for the
coverage verification and that failure to secure mvamp under Scc6oa 25A of MGL 152 can Icad to the imposAlon of criminal pen''itics
oomisun of a fine of up to S 1,500.00 andloe imprisonnxai of up to one year and civil pcnartia in dx foam of a stop W o�Orde > a
f=of S 100.00 a day against mw
For depactz:rdal use only
/ Permit Number
Lot 4
signature of Li ermittee ut-- Le
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
SRegitered Homeliriprovement Cii'ntrac or: �* w 4 Not Applicable ❑
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...... ❑
11: .4�Hom`e D wner Exempt on
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 buildinV 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' ('+.�mpensation) 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 nd Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
. z
SECTION 5-DESCRIPTION'OF PROPOSED WORK(check all,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: Cv�� \�`L`"`tc�
Alteration of existing bedroom Yes�= No Adding new bedroom Yes �` No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet o
6a 'If"New'houseantl°nor atlditionYto ezistmg.h'ou`sin�; complete`_the followin :
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
as Owner of the subject property
hereby authorize to act on
my beh If, in all matters relative to wo:k, authorized by this building permit application.
G�
2c ALL-/
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 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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
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 #
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:
y Northampton S
^ "iI i g Department rb utl eve
MAY 2 4 2002
` Main Street erne _► . a
1 oom 100 Water el Avaaq a:
,ASP,tc' Aktha pton, MA 01060 two se, .7b ruc ral ae
' " 240 Fax 413-587-1272 Plot%Sete Plas _
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -`SITE INFORMATION
This section to becompleted by office
1.1 Property Address:
tln
y d
Ma' p
t
z a ' Lot� � l l
4t
4 Zone OverlayD�strict�� •��,�
Elm St. District " CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name( rint) Current Mailing Address:
-e �> CL- Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION C05TS \Q ,
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit apnticant
1. Building (a) Building Permit Fee
2. Electrical (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) \C_ Check Number D
fThis Section For Official Use Only
Building Permit Number: (I�J , U1 Date Issued:
Signature:
Building'Commissioner/Inspector of Buildings Date
File#BP-2002-1041
APPLICANT/CONTACT PERSON ALSTADT KAREN L
ADDRESS/PHONE 84 CHESTNUT ST (413)584-8374 O
PROPERTY LOCATION 84 CHESTNUT ST
MAP 17C PARCEL 158 001 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 late/ 91�mu
T_ypeof Construction: REPLACE KITCHEN CABINETS SINK&WINDOWS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9AMATION 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 scion
Signature uilding 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.
r. ' t�rs BP-2002-1041
.,
GIS#: COMMONWEALTH OF MASSACHUSETTS
t iss CITY OF NORTHAMPTON
Lot:-00
Permit: Buildin£
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-1041
Project# JS-2002-1675
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 6185.52 Owner: ALSTADT KAREN L
Zoning.URB Applicant: ALSTADT KAREN L
AT: 84 CHESTNUT ST
Applicant Address: Phone: Insurance:
84 CHESTNUT ST (413) 584-8374 O
FLORENCEMA01062 ISSUED ON:5131102 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE KITCHEN CABINETS, SINK &
WINDOWS
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 5/31/02 0:00:00 1267 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
TI ON 8 -.CONSTRUCTION SERVICES
jt 8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address r' ' Expiration Date
Signature Telephone
. -. 6"Nt
` e t Ttrao� Not A pp licable ❑
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...... ❑
®caner xemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(?) 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 Chapte- 153 (Workers' C(l,npensation) and Chapter 153 (Liability of Employcrs to
Employees for injw n-_)t resulting, in Death) of the General 1-,aws Annotated, you nrav be liable
You hire to perform work for you under this pernit-
'Fhe undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, (-ity nl
Northampton Ordinances, State and Local Zoning,Laws and State of Massachusetts General Laws Annotated.
I Iomeowncr Signature
OWNER D SHEET LOT
ADDRESS 84 Chestnut Street 17C 158
APPLICANT TEL. ZONE URB
ADDRESS DATE OF APPLICATION
ZONING APPLICATION APP. DATE FEE PLAN
BUILDING PERMIT ISSUED DATE FEE PLAN
#632 10-17-90 renovate bathroom $40 sketch
#BP-02-1041 - 5/31/02 - Replace kitchen cabinets. sink & windows$50
i
CITY OF NORTHAMPTON FINAL APPROVAL BY DATE
BUILDING INSPECTORS
V
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CHECK It jr 703 AMOUNT
d �5
l it JUL 9, 002 ACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
_ E ( tint or Type;
NORTHAMPTON Sass. Date Ae) Permit u &P6 3- dt 3
a J�. Owner's Name
Building Location-1 Ci�t-rl �" kar'en (XIS{-aCt�-
�-(DYe;nc e Type of Occupancyj( � rhQ
New ❑ Renovation ❑ Replacement �+Y' Plans Submitted: Yes❑ No ❑
X c
N N U � i- S
n cc ¢ O ^ r -
w w ¢ O U p 1_ _ •n
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FU- �_{G W 7 Uj
Ir w O V w O J C< U> u
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SUES-35MT. - --- --,- - _
W t,6 Lj BASEMENT _ _ _i I i—�+
m z < ST FLOOR
0 _2 I —
G Q ND FLOOR i
Uj
SRO FLOOR 1—H
� 1
0 01 �!' 4TH FLOOR
_j 5TH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR I
Installing Company Namehfl�iC�hA i iL1rnb111Gf L I�&a�L + uric• Check one: Certificate
Address�P.P � >k__??� / 11Y� Y( } --- — Corporation 1
nlo cI _ ZIP ----- 1 a tnership
Business Telephone �3-,S0- I V3`-I [J Firm/Co
Name of Licensed Plumber or Gas Fitter
�INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of f;iGL Ch 142,
Yes V No ❑
If you have checked yes. please indicate the type coverage by checking the appropriate box
A liability insurance policy Other type of indemnity❑ Bond 'Di ;
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the t,/lass- General Laws. anc that my signature on this permit apq`i.catior, .,-:awes this requirement I
i
n C,hec k Cif 1e
_. 1
Agent []
;!ynature of Ovner or Owners Ageni
i hereby cerl,ly that all o1 the details aril utlotmation I have subtitled lot entered)in above appficailon are live and accurate to the best of my
F,nowlcdge and that all plumbing work and installations f>erlormed undar the permit issuad for this application will be in Compliance with ail
pertinent prori Ions of the M3s,achusetts Slate Gas Code and Chaptz�, 14L of i _General wv.; 1
By - --- -- T o1 License l.A}�.: �� r fl
Plumber S gnalure of L censod Plumber or Gas filler
Gastitter
Master License timber L�
City/Town Journeyman ------- — -- -
MPKIVED tOF'FICE US ONLY
PRINT SNOP
n --
�� MASS ► USETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
i J 002 (i�n4�a�Typal
Mass Date, Permit# 6 I
Elzetr r.. 84dh'g Location i3� owner's Name
4r11� Type orr_ ���11�14
New ❑ RerAwabon ❑ Replacement M Plans Submitted: Yes❑ No
FD=REs fe
= x r a
p7 m M o = _ } t,
4a x
�'►1 O w ;.S N M <N" h a 2 U< S y=0<0 Z< I. 0.¢
a 3: h x
x I <O
S
w x w 39 IL 0 t y ~ O r r a Z w O C1 S
-- - - -0_
U BASEMENT
, j < SST FLOOR
�-' (n j 2ND FLOOR
3RD FLOOR
s < 4TH FLOOR
(5 ~ STH FLOOR
e.TH FLOOR
Lf_• 7TH FLOOR
.. Z
C m :, aTR FLOOR
lj_Wjing Company Name Plt lb�tiq & Heating, Inc. Check one: Certificate
P_O. Bkxx 323, 131 Main Street McCocporation 14230
Haydenville, MA 01039 ❑ Partnership
Business Teiaphcne (413) 584-1534 ❑ Firm/Co.
Name of L.ceased Plumber Robert B. Schneider—Master
INSURANCE COVERAGE:
I have a.curW*fiabW hswwlm pocky or Is strbsiarttlal egkrivater}t whkb_meds the requirements of MGL Ch. 142.
Yes fl NO ❑
If you have crecke .M please Indicate the baps coverage by dmddng the appropriate box
A liability insurance policy ® Other type of indemrmy ❑ Bond ❑
OWNER'S RiSUpjk% tt WA aM:5 can aware*A Sfie Scansea does rick hawe the kwurance coverage required by
Chapter 142 of the Mass. General Lays. and that my signature on this permit application waives this requirement.
l Check one:
Sign�rs�o�iirirer 'L� owner ❑ Agent❑AQWd
I bersby co tify drat aN of tto detslis and inform ion i tars wb rAWd(or ant red)in above appicabon arc true and accurate to the hest of my
krwwledge and that all durnbkv work and irsfaildlom porfoimad.urxier the permit issued for this application w N be in comglimce with aM
QQWWA 9"Wilion at tea�Stela . Oaft wA ChWW W2 at 1"Qwmt UHL
of Uowmd r
Title
Type of Lksnsa:Lust"r] Joumeymao 0 $
- /Town
txenme wsrrb.r 91 7 0
Chk #
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"$ -itV of Xort4ainpton z F
�A35AChli5ttt5
�y DEPARTMENT OF BUILDING INSPECTIONS
f t
INSPECTUpbruary 18, 2003 212 Main Street • Municipal Building
North,unpton, MA 01060
r
Ms. Karen Alstadt
84 Chestnut Street
Florence, MA 01062
Map 17C Lot 158
RE: Building Permit#BP-2002-1041
Dear Ms. Alstadt,
You filed for a building permit on May 24, 2002 to replace kitchen cabinets, sink, and
windows. The permit was approved on May 28, 2002 and you applied for the permit
acting as your own contractor signing the home owner exemption form (copy attached). I
have looked at the inspection records for this project and find that you have not called for
the require rough building , insulation and final inspections. I also see that your plumbing
contractor has not received a final inspection for gas range stove installation and
plumbing for kitchen sink. The electrical contractor has received only a partial rough
electrical inspection and no final.
I hope that understand that you are ultimately responsible for the work being performed
as you signed under the home owner exemption, I also hope that you understand that you
place yourself and your families safety at risk by not securing the required inspections as
required by law.
Please call me at 587-1240 so that these issues may be resolved.
Sincerely,
Anthony Patillo
Building Commissioner
City of Northampton
CC: Inspector of Wires G. Fournier, Inspector of Plumbing and Gas R. Balise