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17C-187 (7) rc, ayO� JUN 2 0 2002 ; ,J G TCTIONS INSP ILI OQ�tpTO - 4 $ B �asaachasrtta m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S CO ON INSURANCE AFFIDAVIT 1 Id (Iierl s permittee) with a,f al lace of business//residence at: b Ne it F'!i+✓l'E > � Ol d i d (phone#) (strCei/city/stlW2/ p) do hereby certify, under the pains and penalties of perjury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees worlang on this job: Once 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) +r. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compan y/policy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach a6ditioo3l shed ifncccssiry to mc}ude infwtninoa pertniuing to all oont ciors) ( ) 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 homeowners who employ pa:om to do m,k r „n omstri too or repair work on a dwelling of not more than throe units in vAnch the hotnoowncr rrsidcs or oa the groins appurtenant ihcrdo arc no(gully eomukrcd to be carployrrs under the workers o0aTcmation Act(GL152,m 1(5)) application by a homcownis for a Uccose or permit may nidcnoc the legsl ctatva of an employer under tho WNkeeg Compemaiion Ac(. I underA,nd thsi a oopy of this vh cmmt may be forwarded to the Dcperta,cat of Lsdrutrial Accidw&Ofboe of I.0-for the cover g vcrificatioa aad that failure to s==coverngo uudct scdioa 25A of MOL 152 can Icid to the intpositioa of criminal pcnalt cs ooqustimg of a fine of up to S1,300.00 and/or imprison of up to one year and civil pcmltia in the form of a Stop Work Order and a fim of SIoom a der against me For dcpartmcsfal uao only Permit Number Map# Iat 4 Si of LicenSW1Permittee e SEGTI0N'8 '-;CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone �.. r. . men n r Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-.WORKERS';COMPENSATION INSURANCE AFFIDAVIT(M.G.L.rc. 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...... ❑ 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 faun 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, Sta and LocW Zonj Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5 'DESCRIPTlo'"F PROPOSED WORK(check.all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) 2�( Roofing ❑ Or Doors IV Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: 3 Ad +n _AU Ott 002.5 Aid fMe.✓ Odd kX /NN Alteration of existing bedroom / Yes No Adding new bedroom_ _Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet X sa If.iVei hou elan' r0r%'dd tidtlJoYstthk;housing;°coIli0Wf the'fotlov MEI: 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, UTH QRIZATION TO BE COMPLETED WHEN OWNERS.AGENT. R CONTRACTOR APPLIES;FOR BUILDING'PERMIT I, 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 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. 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 Z( 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: of Northampton E C Iding Department but 12 Main Street 5 f ` Room 100 a ° JUN 2 0 2002 1 ampton, MA 01060 so. phone 413-5K-1240 Fax 413-587-1272 Pto tt�e DEPT Of BUILDING INSPECTIDNS - UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be Fompleted by office , 1.1 Property Addres �4 z in Map, Lo# g lU r, overlayDistrtct � � - h , Elm St. District ?CB Dlsirict SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ' il r , 40 �I �. c f�NL{ .J? rleWore �_/ode Nam Print)v Current Mai lin Address: .500 Telephone Sig ure 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 1. Building �, (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of �-S© ' Construction from 6 3. Plumbing ya/`5 00 Building Permit Fee 4. Mechanical (HVAC) 7 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) S60 �" Check Number This Section For Official Use Only Building Permit Number: Date'lssued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2002-1142 APPLICANT/CONTACT PERSON DELLA PENNA CRAIG ADDRESS/PHONE 62 CHESTNUT ST (413)586-9853 Q PROPERTY LOCATION 62 CHESTNUT ST MAP 17C PARCEL 187 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction:_INSTALL EXTERIOR DOORS,2ND FLR BATH&KITCHEN CABINETS 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 INFQRMATION 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 Commission ii�l "4 lzur,-� ( ,g-1, 4 ;� Signature of Buildin fficial 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. 62 CHESTNUT ST BP-2002-1142 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block: 17C- 187 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2002-1142 Project# JS-2002-1838 Est. Cost: $17500.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): 20298.96 Owner: DELLA PENNA CRAIG Zoning: URB Applicant: DELLA PENNA CRAIG AT: 62 CHES T NJT ST Applicant Address: Phone: Insurance: 62 CHESTNUT ST (413) 586-9853 O FLORENCEMA01062 ISSUED ON:6124102 0:00:00 TO PERFORM THE FOLLOWING WORK:I NSTALL EXTERIOR DOORS, 2ND FLR BATH & KITCHEN CABINETS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring ��11 D.P.W. Building Inspector Underground: )Service: 8 �A]a '"'�eter: / Footings: Rough: j� /`)tough: ,f�� House# Foundation: n�} Driveway Final: Final: C/ Final: QI 1'�',� 5'�''` �'�,ti•o�(yd A , Rough Frame: 0K -Ba Gas: Fire Department Fireplace/Chimney: Rough: `!'1: insulation: Final: Smoke: Final: O kC Gl,3 O a THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. :- Certificate of Occupanc Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/24/02 0:00:00 MO $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo