17D-073 (7) i
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.; OCT 3 2000 ( �C-
k
UIv Acorn,
11 rp
GrTtL) of 'No tllailiptoil
o DEPARTMENT OP BUILDING INSPECTIONS
212 Train Street ' Municipal Duildi:lgp
?Northampton, Mass. 01060
WORIQ,R'S COi UENSATTON LNSURANCE AFI DAV-IT
---
\r.rith a prmciprl place of business residence at:
QCV-A1C.P_- (`�� Cy U(p -- (ph one:=�J
t (str=t/clty/stale/np)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing dic followine %vorlccr's comocns-�:ion coverage for Illy
etuployccs wortaing on Oils job.
r(lnsZ r� Corm (Pcbc-, Nu_-nirr) F---:pinion Datc)
' I ant a sole proof;etor, general coou-aaor or omeow-ou ,cie oee) and have hired
the conuactors listed below wbo h2ve the following worker's coWnensation policies:
(i ril^ 0� Con -: 1ci0") (111 nnc COIIIDI]}'/hGl]Cf it1I71CC) (L'?:i)lillt:•Q I��IC)
(Naine of Comz!mor) (IJtsrlranc ComoawiPolicv \'tunccr) (ExDiraion Date)
(Name of Coturaeto,) (Lnsuranc: Compan)•/PoUc) Nuinb�i) (&pLmdoo Date)
(Name of Contractor) (Insurance Company/Policy NumbJ) (Expu-d6on Datc) ,
(mach-"3di ocil r a if occ .ry to nc u inform.ioc P-1—nins to au coal--CLO.�)
O I am a sole propnetor and have no one worldog for me.
( ) I am.a home owner performing all the work myself.
NOTE:plcsc be nwlrt tLLd'K WC bOQ]COµVCf]N'60 CIIIpIOV pC:10II1 LO tSJ r-. �-,• �-.- )o:rrQ ..uric oa d..c1Ln�of
not MOM thr- tLm unt'u in\Itl h the pouoF�2rpurtcu:rs tbcd T DJC t=W2-UV ooc-dcmd to be
eavloy—undo the--oc�oe=p,=�lioa Act(GL152s 1(5)�appUcr boo try a bomeo w for e tee.or permit may e 7&ooc tLe
Iegal rtzau of an cgloyor under tldo Wockoet Coaipomdlioa Act
I uo&Q tx d that a Dopy of thid mr®cai—y be fo.-wnrded to tbo Dcpvuncoa of ofrioo of lra+u.noo for the
oovcr*se vaif caioo"t1Lt L•ilt:rc to secure`covernsc trader scetion 25A of MOL 132 can lad to the izmposltioo of erimi"PCW-Wes
comuting of a fine ofup to 51.300.00 and/or ixnisoomcai of up to oroe ycar acd civil peadl'uo in r`x form of a Stop Work Order snd a
fim of 5100.00 d dip tPiast roc
For d�uuz.�udc Drily .
�� Permit Number
\ )`bp:i_ Lot
J St�natun of Li crmiucc ��
SECTION 8-CONSTRUCTION SERVICES "
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
., 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...... ❑
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.
H uda om eowner Signature O
SECTION I R 0040 WQJRK(chtgk all anflob e
New House ❑ Addition ❑ Replacemen endows Alteration(s) Roofing ❑
/ Or Doors
Accessory Bldg. ❑ Demolitionov New Signs [ ] Decks [ ] Siding[ ] Other [
wtl n kittlx�n c c�bi°�er5 (WAX,VAthtinm fixates (n F
rief Description of Proposed Work:Neutki�e F1ocC��cerne+lt W1c�Aw7,n ��
4m vtd
Alteration of existing bedroom Yes r/No Adding new bedroom Yes 1/�No C.�'t
Attached Narrative� Renovating unfinished basement Yes _Z�No�a)
Plans Attached Roll ❑ - Sheet q/ l
JV
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
O VNt= S AGENT-00 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
f" �` ,k C'CQ< Mtic) as Owner/Authorized Agent
hereby declare that t 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.
PK% I d- &��a UG-
Print Name
04-t>/00
Signature of Owner/Agent Date
J ,
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 y 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:
City F rthampton
n
3 201d in epartment
21 ll�in Street
DEPT of alsF `,a�, f t oon 100
Amplon, MA 01060
phone 413-587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
his see w
1.1 Property Address:
;M � '
y
Eire St."IIst �f#' �� `
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
AC�kla
Na/m'ge(Print)
1 � Current Mailing Address:
J��iI)k Telephone rL�,2��� / /
Signature 1 J OLj
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION'COST5
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
.1. Building 0 WD c�
(a) Building Permit Fee
� � . Q
2. Electrical g I +ow pct (b);Estimated Total Cost of
Construction from 6
3. Plumbing i dQ0 , Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4+ 5) 12 v cD Check Number
This Section For Official Use Only
Building Permit Number: bate Issued:
Signature:
avilding.CommisMonerllnspector of Buildings Date
File#BP-2001-0366
APPLICANT/CONTACT PERSON GREGORIO ARIELA
ADDRESS/PHONE P O BOX 478 (413)268-9044 Q
PROPERTY LOCATION 30 HIGH ST
MAP 17D PARCEL 073 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building-Permit Filled out
Fee Paid 31 O
Tvpeof Construction STALL REPLACEMENT WINDOWS KITCHEN CABINETS,NEW BATH FIXTURES
&REDUCE 2 CAR GARAGE TO ONE
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 F SkLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
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 Commission Permit from CB Architecture Committee
Signature o uild' 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.
30 HIGH ST BP-2001-0366
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 17D-073 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category'Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0366
Project# JS-2001-0596
Est.Cost: $12000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 9016.92 Owner: GREGORIO ARIELA
Zoning.URB Applicant: G R E G O R I O A R I E LA
AT: 30 HIGH ST
Applicant Address: Phone: Insurance:
P O BOX 478 (413) 268-9044 ()
WILLIAMSBURG MAO 1096 ISSUED ON.10 16100 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS,KITCHEN
CABINETS,NEW BATH FIXTURES & REDUCE 2 CAR GARAGE TO ONE
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 10/6/00 0:00:00 378 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
1