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�, DEPARTMENT OP BUILDFNG INSPPCTIOI.'S
212 Main Street ' Municipal Building
Northampton, Mass. 010GO
`VORICER'S CO)UENSATTON LNSURA-NCE A FTITD AV1T
01 crusc&permj ttc c)
%with a principal place of business/residence at:
(phonef')__��
(Samf,u ity/statc ip)
do hereby certify, under the pairvs and penalties of perjury, that
( ) I am an employer providing the following workers compensation cove age for Inv
emplovees working on Otis job
(lasur-nc-- COGl>::Y) (POLL-"NUnan-r) -- - (� :piruor Datc)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the foUo%VU* g worker's raonensation policies:
(Name of Cont:-acto-) (In-umncc Comoam-01 ouc, Numbb:-) CEX—Pmdt:on Date)
4r
(Name of Contractor) (Ossrance ComoaayvPoliLy Nulilccr) (ExpL iron Dale)
(Name of Conn-aclor) Riasurancc Comp w y/Pouq- Number) (Expiation Date)
(I`'amc of Contractor) Rasuranc-- Comcaa},/Poucy Numb:r) (L-xpnr ion Datc)
(nnaeh ad.�.i::oeil sxet it❑<c sry to mcludr uxfonm-snco pertaining to a1J
J -I aM a sole proprietor and have no one worLang for me.
( ) I am a home owner performing all the work myself.
NOTE: s:c e (-
I b cwarc h
p W u1.^Jc 6oaro«vcr�ubo cmplay pczom to do c^.�ca��,c --.r�xt c rt,-xiu work m.d.•cll=g of
ON more thn t'ua tmi'l in u-b cb the twcvo -.nzvde,oc ca the awl-zppurtrn:r!tbc� ,ax gee 11y occ".6--c7 w be
ci:tploy—utt,c the ocap�-=lion Act(GL1 application by e hoo oo-ocr far:l c5x a permn r=Y n16CQoc LbC
IcjPJ rtnnu of Rn cxployor under rho Workce K Compoc—Lion Act
I undcrrtand the x copy of this cxalcsml may be for�.nnlnd to tbo Dopartu_I of ic>d,�srial Amdc j Offioo or ln-a ira000 for rho
oovm se va-1GC11,00 and a'-t L-Au c to L'0 u eoveruge tinder soetioo 2 S A cd 1.toL 153 can Iced w tbo uxxp Qioa of criminal penawcs
0001i3 i, g of R fine of up to S 1,500.00 uoor¢iipTLSpam oCup to ooc year eud civil pcvaluo in dK form of n Stop Work Order and e
Cim of S 100.00 1 day plost me
For u,c ortly
Pcnmt Nl1IDUC1 -_--
? Lot
SiGnacurr of Lio scc/Pcrmr Ltcc ��
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iAl�13 C�?NS;T1:tUCT1fJN�EI�VICS
o.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �a�l l is �S E�� 06,Z' q�
License Number
Address Ail n � �J Expiration Date
�;P (AEI �C/ ��
Signature Telephone
Not Applicable ❑
OM qLA - stn& AA
Company_Name Registrat ion Number
/
Address Expiration Date
Telephone -3S�
SET1fN 1Q YMQRERS'GCMPENSAT1 11 NfttA11T{1A: i c X52, rS G{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.
ned Affidavit Attached Yes....... A ' 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 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 Signature
epll-
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New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors K
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes_�_No Adding new bedroom Yes _�No
Attached Narrative❑ Renovating unfinished basement Yes No
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
Energy Conservation Compliance. Mascheck Energy Compliance form attached?
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
SE�TlQ 17a-0WNER'AUTHORIZAT{0,N -TO BE COMPLETED WHEN
IYSINIrF S AG N'T OR GOPI'TRAGTt WAPPLIES l:OR BUILDING PERMIT.
I , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters reI i to k author ed this building permit application.
c
Signature of Owner V Date
as Owner/Authorized Agent
hereby declare that the stat ments and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
,igned under the pains and penalties of per.ury.
Print Name
Signature of Owner/ ent 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. Arp 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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1J Ci Northampton
I 0 2BBla I g Department
Main Street
om 100
OEPT OF P!W '`e'r,P`„2 ^ ,,Tl 6
ry NnP a pton, MA 01060
phone 413 587.1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
��CTI"t,�IV 1.`S>T�II�1Ft�RMAT1f}t�
�q
1.1 Pro er ty Address:
MR-
�FIQ" AeD
> IQN 2 y ?ROPER7Y OVI NERSHIPlACJ7t100, AGENT
2.1 Owner of Record:
ti) 1A C �7 l S . F"CQ
me(Print)
(d. Current Mailing—Ad ress.
Telephone
Signature
2.2 Au horiz A e t:
a2 cc
Name(Print) /r Current Mailing Address:
Signature Telephone
�” t 3 STI1Vf�T CI CONST
Item Estimated Cost(Dollars)to be Off�cial` le On,l
completed by ermit applicant
1. Building ? (a)Building Pi Fee
2. Electrical oco .co (b)Estimated Total Cast of
Construction from ii.
3. Plumbing Building.Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
lu
6. Total =(1 +2 + 3 +4+ 5) Che i $tmber
'dais Section.Fnr Official US10M
uildiz Permit'Number: Date Issued:
l 'te't�at"e
. ut ltNj�g-£ rrimisQrterllrrspectc�r of Bciltfngs Late,
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File#BP-2001-0154
APPLICANT/CONTACT PERSON Paul McCutcheon
ADDRESS/PHONE 87 Chestnut St (413)584-3352
PROPERTY LOCATION 30 STRAW AVE
MAP 17D PARCEL 034 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
Tvpeof Construction: REMODEL BATH&INSTALL REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessoly Structure
Building Plans Included•
Owner/Statement or License 062544
3 sets of Plans/Plot Plan
THE/LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
W Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § _w/ZONING BOARD OF APPEALS
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 Commis ' Permit from CB Architecture Committee
Signature of Building OfficiaF 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.
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30 STRAW AVE BP-2001-0154
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-034 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildincl
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0154
Project# JS-2001-0249
Est.Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Paul McCutcheon 062544
Lot Size(sq.ft.): 5096.52 Owner: MCCUTCHEON PAUL C&MARCHELE
Zoning:URB Applicant: Paul McCutcheon
AT: 30 STRAW AVE
Applicant Address: Phone: Insurance:
87 Chestnut St (413) 584-3352
FLORENCEMA01062 ISSUED ON.8115100 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATH & INSTALL REPLACEMENT
WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 8/15/00 0:00:00 183 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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30 STRAW AVE BP-2001-0154
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-034 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0154
Project# JS-2001-0249
Est.Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Groin Paul McCutcheon 062544
Lot Size(sq. 1): 5096.52 Owner: MCCUTCHEON PAUL C&MARCHELE
Zoning: URB Applicant. Paul McCutcheon
AT. 30 STRAW AVE
Applicant Address: Phone: Insurance:
87 Chestnut St (413) 584-3352
FLORENCEMA01062 ISSUED ON:8 1I5 100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL BATH & INSTALL REPLACEMENT
WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
i
Underground: Service: Meter:
n/o l ootings:
Rough:,k ��, � �� j Rough:V l House# Foundation:
Final• 1311
rcvw Final:90A�t�l�y
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: o
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc tSienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/15/00 0:00:00 183 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo