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w` o DEPARTMENT OF BUILDD7 C INSPECTIONS
212 Alain Street Municipal Building
NorthampLon, A1ass. 010GO '
i
%V0PU :IZ'S COMPENSATION MSUTAhCE AFFMAVI-l'
(li ccnsaJjx-rmi tttx}
v,1L1 a prUicipal plat,- of business/residencc at:
c�. (phonc`')
(SIIr /c7ty/ fnp)
do hereby certify, under the.pa-ins and penalties of perjury,, hit
( I am an employer providing the follo.ving t:orl:c�s comocasado� covemgc for Intl
emptovees wor lig on tius job:
I q�
(I2na1-an= Comm,) (Poiic: N -nocr)
O I am a sole proof-ietor, general coouacor or homeoWDU (arcie o.r2e) a.ud La.•e hired
the coon actors Listed below crbo hive the fotlo ing wore�s ranoerLtadon pe.licies
(Name of Coat aaor) (In2r3nc Cornoan}vi'olic; ?`urn c:) (r_+:Pi•-a�oc [}atcJ
(NaL.I•C of Cootraor) (Insurznc Com>7aa�vPo!ie; \tznc^r) (Lx-Di Date)
.L
(Name of Corm clog) CaiaLraacz CompanyfPoUq- Number) (Espiraen Datc)
(Name of Conaaaar) (In-svran Comp,-_ y/Policy Numb•:r) (Expit�;on Darr).
(a¢sd=du2:oca1 dcct.if ncc l-y iafortnLE oc p=—Zaiains to au mcccLon)
{ ) I am a sole prop
netor and have no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE:plea be ewztc tb*•w-L-Jc bemc ,-o-n Bubo co=p Icy Dc=.O.M w do- c=_—c,uo or rc; u. rk o,a d..cl1_ of
act most 11.3 ti=att to wtm6 the bomoowvc raidm or ca the poerac r,ppurtc-,= tbcs•,o r--c oo(C . Dy ones&.—Cd w be
cxployes uar`,e the..u-S;d:�--.•'�Aa(GLl S 2�t(5)�,�pliariw try a 6omeoavc fc:!)�-a pcxait r>�y c.�dcx.�c the
Icyl cL—s of an cp loyar=dar dtsn Work,-!,C,omp.00s �-
[uade-szaad tha>Dopy of tlssa mtcraz may ba fors.-e,•d.>d to tbu pope-r•.meoi of lndurri el.uade�.z'Ofrioo oflsu�n�far tb..
coves°`w�C=ioo and tfu fc]`''t'r to —1:Goa 25A of),(oL 152 an lcd to the i=posaioa of aimiaa!pca L6-
coc=LT`a8 of a riot orup to 5I500.00 anNor oCup to ooc yr_.-roc,'c�u panliia in tx roan Ora Sop Worti O do aad a
ri=oC S 100.00 i d y Lr i=CD,-
n ;'omit Nt:mt:cr
T dap=— Lot :
Sim,k i` crrniucc I U13 ce F
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction�Supervisor. Not Applicable ❑
Name of License Holder: _ J 0 9ju LA,4?A 1i/ tf pl l 0 375-6
License Number
Addres Expiratio Dat
Signs re Telephone
9 Ri3dlstered Nome Improysrittnt Contractor Not Applicable ❑
Company Name Registration Number
ray �,�6�,/ f-"l►�• 5 sp�/?o
Address Expiration Date
Telephoned/
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...... ❑
bme Owner.Exemption
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.CAM 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition
❑ New Signs [p] Decks [p Siding[E3] Other[a
Brief Description of Proposed / P ',A F, rC Sr yC.
JJ II
Work: ��C�' ee rL�' �c Is ,6' f t4js
Alteration of existing bedroom Yes v No Adding new bedroom Yes `�No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sat if Newhouswand or additio to existing housinfh cMtia]Wte the€otiowiIla:
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. Masscheck 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
I, t�,tvv. /f'`YJt/1// as Owner of the subject
property
hereby authorize -
to act on my 27,77--
A all matters re at to k authorize by this building permit application.
W nature of er Date
�/V I—A A i)P 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.
dA)
Print Name f
4L v �U 6
Signature f er/AsVnt Dat
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete 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 0 DONT KNOW YES 0
IF YES, date issued:
:..................................;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page.. and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
.......................................
Needs to be obtained 0 Obtained 0 , 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 0 NO
IF YES, describe size, type and location:
_.__......_.._.._....__._.._ ............. ..__....._._....................................
_.
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
€OP. ...
City of Northampton ;.tit 0.Off Fetmit
Building Department Gty Pitt
212 Main Street �s+ver:t~erticvt?<IEhlftt
Room 100 tfitryrt(Ne1l Availabrlrty
Northampton, MA 01060 TwocfStrsl P
phone 413-587-1240 Fax 413-587-1272 €16ftiui PEans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: This4ection to be completed by office /
Map lot tf Un�f
t Zone Overlay District
Elm St.District C8 District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
�;^.. r-ko:z L/4 4- J�06,1, 0 1Ir,'Zul-ir /�` i,Ke5 A-'\V�'
Name(Pi t) /Current Mailing Address:
j l Telephone
Signature
2.2 Authorized Argent:
-50'HiJ Z-ALPRi 16Y kia,-ik X-4, 54,
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant 1. Building r2 � (a)Budding Permit Fee
2. Electrical (b)Estimated Total Cost of SO O vd
Constriction from 6
3. Plumbing Building Permit Feed, GU
4. Mechanical(HVAC) (7 D�"
5. Fire Protection
6. Total=0 +2+3+4+5) fl0 Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings date
File#BP-2007-0476
APPLICANT/CONTACT PERSON JOHN LANDRY
ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413)204-9880
PROPERTY LOCATION 66 PINES EDGE DR
MAP 18 PARCEL 002 010 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REPLACE KITCHEN&BATH COUNTER TOPS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 093450
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Comrnittee
Permit from Elm Street Commission
to 30 U�
Signature of Building Official 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.
66 PINES EDGE DR
BP-2007-0476
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18-002 CITY OF NORTHAMPTON
Lot: -010 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0476
Project# JS-2007-000698
Est. Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN LANDRY 093450
Lot Size(sq. ft.): Owner: IRIZARRY ROBERTO ANIBAL&
Zoning,: RR Applicant: JOHN LAN D RY
AT. 66 PINES EDGE DR
Applicant Address: Phone: Insurance:
104 NORTH ELM ST (413) 204-9880
NORTHAMPTONMA01060 ISSUED ON:1013012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN & BATH COUNTER TOPS
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:
FeeType• Date Paid: Amount:
Building 10/30/2006 0:00:00 $50.00706
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo