17C-165 (4) 0
. of Nartijuillpfoll L
a � ,�X�a R(hnGCt14 —
I)EPARI? EhFT OF LtUILDIlyG INSPECi'io;�'S
212 Main Street. ' Municipal Building j
Northampton, Vass. 01060
WOMCER'S COMPENSAITON INSURANCE AFFIDAN TT
L,
with a principal place of business fesidence at-
�r,one.r
(Str U"cIt afe ip)
do hereby certify, under the pains and penalties of,.�tlT�lr- , Oh,< .
O I am an employer providing the followiog v oil:c"s compcns tion coverage for my
employees workirlg on this job:
(Insurance Company) (Folic .r.r1 (Ftpimtioa Date)
O I aII1 a sole proprietor, general co praetor or one) and have hired
the contractors listed below who have the follo.ujcg ,=rr�rk.er's coihp-C.nsat on policies:
(Name of Contractor) (Insu nt Company/Policy t.uml r) (Expirntioa Date)
(Name of Contractor) (Insurance Campany%Policr Number) (Ezpiradoa Date)
(Name of Contractor) (Insurancc Ct,mpal, r'Policj Nlrintr--r) (GipiraCOn Date)
(Name of Contractor) (Insurance Companyd)olicy Numea,) (Expim6on Date)
(attadt additioail r_hr_d if ncccsz.ry tp ix}uctc iafwrrsti oa Ixxiniuing to ell��;'raciora)
( } I Curl a sole proprietor and have no one `corking for me.
I am a home owner performing all the work myself.
NOTE:please be ft-arc that wti7c hocna")wncra who Cmplay pczo:A to d; cr rrpairµone on a& tag of
not rnorc thrn thrco units in which the hontc�"ttcr rra do ex oct the wrou;is y r'cnant tha�o arc r),t gcrtaally cooridcrrd to be
cntployrrs under the wocica'a axrtp5sntiea Act(GL152-a 1(5)),npplicuzion by a homcow oa for a license eC per nit rnzy ni&noc the
Itsl rte of an muployoc under thn Woricoda Compeenatiou ALt
I undcr:tand thrt a copy of this ctatcmmt may he forwnrdi d to tha IYpartrrnt of Indtutrial A.66r �Ofrioa of Its;.u..nw for ti-
cov—&c va-ificstion and that failure to secure covcrn ux�dx section 25A of MOL 152 can Imd to tha imposition of u-i" i peraltica
coasistin of a fnc of up to S1,300.00 Malloc imprium-crif of up to orx year acd civil pmaltics in d)c foon of a Stop Work Ord--anti a
fine of S 100.00 a day igiinst t x
For dcpartmCStal uic«tly
permit Number
r ,,�'G fX ' f Map',t Lot 4
ignahuc ofUccn_,ec/PeruriUce e k.
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name_of License Holder
License Number
,address I Expiration Date
signature Telephone
9. Registered Hon `Improveirient Contractor: 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 a,�d submitted with this application. Failure to provide this affidavit
:viii result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. Home Owner." aemption
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 buildinp, 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 Signatury �' � `ems
r
SECTION 5- DESCRIPTION OF PROPOSED WORK(check-all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
XOr Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other Brief Description of P roposed Work:_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes _No
Plans Attached Roll o - Sheet C
6a. If'NeW.h"ouse'a'tJ or addition to existing housing complete the following:
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 Wocdstoves 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. floodpiain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes_ No .
L 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 behalf, in all matters relative to work authorized by this building permit application.
jSignature 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.
J Print Name
r
"a
tignadreof 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 / 11151-
Side L: R: L:/R: /
Rear
Building Height
Bldg. Square Footage 3
Open Space Footage % x
(Lot area minus bldg&paved
parking)
#of Parking S aces
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:
AL
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B6 i g Department Cur6� t/Dreura.° ._i
Main Street Sewe ISeptic Avaii .
c- , '-),')j oom 100 WaterlWei A ailabili `
i No r 1pton, MA 01060 7wo`Sets of Sfruc traa
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587-1240 Fax 413-587-1272 Plot/Sete Plans � ���� �
C 041°(h O
l ItiG INSPECTIONS
1 ti �rN,MA 60 _
010 ther: peclfy' R
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
Map '' Lot ' Unit
616 Zone Overlay,District
Elm St. District CB District s'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
_t_ . r{_.3.�a►
Telephone
Signa Lire --- _— _
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
completed by ermit applicant
ilding (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from-, 6 _
3. Plumbing Building Permit Fee
r—
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: 73a_(42— Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
File#BP-2002-0326
APPLICANT/CONTACT PERSON ASHER DOROTHY M&CHARLES W SR
ADDRESS/PHONE 50 HIGH ST (413)586-4320 Q
PROPERTY LOCATION 50 HIGH ST
MAP 17C PARCEL 165 001 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
Tvneof Construction: ERECT 10 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
TRpproved LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IATION PRESENTED:
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 mmission
12-71Ze;
Signature of Buildirofficial 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-2002-0326
CIS#: COMMONWEALTH OF MASSACHUSETTS
sokikk
i i65 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: shed BUILDING PERMIT
Permit# BP-2002-0326
Project# JS-2002-0500
Est.Cost:$2280.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin
Lot Size(sq.ft.): 14766.84 Owner. ASHER DOROTHY M&CHARLES W SR
Zoning:URB Applicant.• ASHER DOROTHY M & CHARLES W SR
AT. 50 HIGH ST
Applicant Address: Phone: Insurance:
50 HIGH ST (413) 586-4320 O
FLORENCEMA01062 ISSUED ON:1012101 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 10 X 12 S ED
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 10/2/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo