17C-165 (5) ,limp
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cm DEPARTMENT OF BUILDIIIG INSPECI'iON
212 Main Street r Municipal Jluihiing
Northampton, Mass. 01060
WORT=R'S COMPENSAU0N XNSLIRANCE AFFI-DAVIT
i,
(lictirLSe:J�,I nrittec)
With a l)r nclpal of busir)es's/residence at:
jp'P'nei�r _
�5t2v;t�Cl t��SLIIP�Il P)
do hereby kinder the pains and penalties of penury, t lac:
an enspl�,ycl providing the following workcl,s comi;ensation ctr✓e:age for my
employees wc)Ck-ing on ties job:
--- - --------"
c 1 ,l so) 7i c)r �IOI f'P:.ral COIItrc C`OC 1, : ! O." i ilG .i3Vf l�Cd
the COI:t`FaC„� llstt.li below Who have the fbno „r�F'hS CC;Lii) .il �tIGP� poliG1PS:
C',1ame of n!ra tort (Insurance Con:pzny/Pohcy Numb.;r) (F > ) anon Date)
(dame of Car.tran–,I) (F.xrintion L)P!-,)
('Nalne of (Insurance: CompauyPl olicy �i s^ Date)
(Name of Contractnr) (Losurance C01L1"allyRoky i tumtr ) f xpi _tion Da(e)
(ntL'.,-±t acSditiocal s'rnt i-.,.c csvty;r,to-=:w}c u.°ocnu^on pcstniuin�to ail cr�+-ndcn)
O I un a sole proprietor and have no one workinc, for me.
O I aIIi a home own-,:- performing all the work,myself.
NOTE:ptcssc ix �}irile hotncou_xts%vho�---,)!ay pcs :_r to S) a a:u .x,a:r r c :«c::cpait'.4'uti cn a dNscll g cf
not tn<x-th.n Lrot units in the ho-,,eou ocr midcs or cct the pr unc}s apputtsnart tti,- o a cr0( ncnity Px:sidcrcd w be
rnployc:s L,:N s the wo i cis cxs pc-,.utim Act(GL15'"1(5)),nppldc tL6m by a homeowner for a li uc o permit n:ay cv"cr-oe th.
1eg�x1 ctnhrs of nn a ployec under tho Woricc:'s Cotnpmsaiion Acx_
I undcrsvnd chit a copy of lids ctatcznaat mny be forwardad to tho pcpc,tmcat of lr>dz ial Atcid:;&Q.!io0 of Ln�'—for tho
covmge vcrificsiioo and that fniurc to sxure oovcntgo ur-x sxtion 25A of hiGL 152 can l"d to tho imPosLioa of criminal penalties
oomisiing of a fine of tip to S1,500.00 attd/ot uupxiiorsnxaY of up to cxte ytar and civil penalties in tlx fexrrm of n Stop Wmt Ord and a
film of S 100.00 a day agsitbst ter-
i
dcpartnnr-eSi u o«31y
permit Ntnn>cx --
ivflp'f I.,ot ri
Signature of Liccn_ec/Per>vittce L- e-
r i
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9:RegisferedHomelrriproveinex�t Contractor�,,,,, , 4 ,` �,,,_, =,, . =n„ �,� Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compe nsation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavi
will result in the denial of the issuance of the building permit. _
Signed Affidavit Attached Yes....... ❑ No...... ❑
11. ��.Hoe Owner�xempaon
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"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 L 4�1 ✓ �� f�
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition New Signs [ ] Decks [ ] Siding [ ] Other [ ] -
Brief Description of Proposed Work: ri�c — --
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a.`If`New house and or.`addition to existing;housing complete the following:
-3. 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
_ Number of stories?
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 behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 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
ignat re f Owner/Agent Date
s
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:
4 �
�'
Northampton Status o 1'er t
E l� E 0 V i g Department Curb C-Ut/�Drlve Syr ruin
1 Main Street ewer%Septic A aliab°I
� om 100
EP 211 W�aterlWeil Ava labiiiy �
L
orl pton MA 01060 Two Sets of SFUC uralPJarr �
phr)rip 4-1 87 240 Fax 413.587-1272 PiotJSife
DEPT Of BUILDING INSPECTIONS Other.Specify
r
NORTwOMPTON YA 01060 i
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_ Lot-/
Cam— ,, 9 D�� Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/L40,&-,0VC
Name(Print) Current Mailin Adcress:
Telephone
---
2.2 Authorized Agent_
Name(Print) Current Mailing Address:
I
i
Signature Telephone _
SECTION'3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
comp feted by permit applicant
Building r r �^ ¢' (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4 Mechanic'l (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit''Number: � Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0314
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
Typeof Construction: DEMOLSIH 3 CAR GARAGE(NO UTILITIES)
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 TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P SENTED:
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 Commissio
Signature of Building Official ate
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.
'SQ II�&H ST BP-2002-0314
GIs#: COMMONWEALTH OF MASSACHUSETTS
4 : 17C- 165 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: demolition BUILDING PERMIT
Permit# BP-2002-0314
Proiect# JS-2002-0478
Est.Cost: $1000.00
Fee: PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
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:9120101 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMOLSIH 3 CAR GARAGE ( NO UTILITIES)
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 Tyne: Receipt No: Date Paid: Check No: Amount:
Building 9/20/010:00:00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo