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23D-156 (3) 150 MAPLEWOOD TERR BP 2002 0614 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D- 156 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:ADDITION BUILDING PERMIT Permit# BP-2002-0614 Project# JS-2002-0957 Est. Cost: $20000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Roger Clark 021310 Lot Size(sq. ft.): 23086.£O Owner: PATENAUDE BARBARA M Zoning: URB Applicant: Roger Clark AT: 150 MAPLEWOOD TERR Applicant Address: Phone: Insurance: P O Box 34 (413) 584-1170 LEEDSMA01053 ISSUED ON:1/4/02 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 6 X 12 TO LIVING ROOM & ADD FIREPLACE 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: ,, ,U House# Foundation: 'I T -/ 3 '-©d -i Z e--" -_ Driveway Final: �' `- Final: Final:OpI0 Z r Rough Frame:Cfr 7` 9', v� .4,11 Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: OK GI-//` 02 --1fr THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. , . "7°°,,,,:f_ l Certificate of Occupancy.-- Signature: ` 4: ''� Fee Type: Receipt No: Date Paid: Check No. Amount: Building 1/4/02 0:00:00 4454 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 1 , File#BP-2002-0614 APPLICANT/CONTACT PERSON Roger Clark ADDRESS/PHONE P 0 Box 34 (413)584-1170 PROPERTY LOCATION 150 MAPLEWOOD TERR MAP 23D PARCEL 156 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid �"9,$"e/ 11050 Typeof Construction:_CONSTRUCT 6 X 12 TO LIVING ROOM&ADD FIREPLACE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 021310 3 sets of Plans/Plot Plan THE FO OWING 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 Committee Permit from Elm Street Co ss'on ZOO Signature of Building Official Dat 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. II �--- Department use only II vi [tit Northampton Status of Permit: �` ! Bt{ulg Department Curb Cut/Driveway Permit [VlainStreet Sewer/Septic Availability_ _ JAB 2 � om 100 OZ +' ` . Water/Well Avallablllty Nort amoton, MA 01060 Two Sets of Structural Plans__._______ DEPT Of BURt14i1M, r4-Gliap 7.1040 Fax 413-587-1272 Plot/Site � NORTHAMPTON,MA 01060 Other Specify 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: Map ()3 D Lot /5-62 Unit r SO /'2dP e stood %c rc'At Zone 2„,,er ` ' Overlay District Pior�xce� r/ Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: &its'6 ro l a te-A a 0a1 c /S4 /c?..p a e( 7-e r; r-10 rcktte 010 6 k Nam Print) Current Mailing Address: S-�v— �a9y Telephone Signature 2.2 Authorized Agent: P' C kt r tC !so L.ceI s/ a1OS3 Name(Print) '� Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 9S00 2. Electrical 5-0 (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 + 4 + 5) „ .0 O0O Check Number 0/3-6-7 5a This Section For Official Use Only Building Permit Number: p rV it Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 1 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 3 4 crc.s r1 j/ FrV Frontage /30` (t in{, Setbacks Front 'j/p / 50�,,.e_ a Side L: R: '30 L: Rear V.r+CS 30`Toiro' Stet / a Building Height 3 0 i 5 4.n. Bldg. Square Footage bd a 7 % . 3 Open Space Footage % (Lot area minus bldg&paved a a (IMF ‘2_ 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: SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ta1 Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: add, 6 'X14-1 To I ivi.ty Pe ern just a-w4lls )-rooP fi- awl S;r`cP 6.c,t___ Alteration of existing bedroom Yes V No Adding new bedroom Yes !V No Attached Narrative ❑ Renovating unfinished basement Yes ✓ No Plans Attached Roll 0 - Sheet if Oalif lewatiouse=andror addition to existing housing, complete the following: 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? /Vp d. Proposed Square footage of new construction. 7 A. Dimensions G /X la e. Number of stories? O R f— f. Method of heating? el"iS f ny, Fireplaces or eves Number of each I 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 s"' Yes i j. Depth of basement or cellar floor below finished grade 6 G k. Will building conform to the Building and Zoning regulations? ✓ Yes No . I. Septic Tank City Sewer ✓ Private well City water Supply V SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I Pa 1 L° Iy_ 14,I �, , as Owner of the subject prope hereby authorize IZdge.n Oar k to ac my half, in all ma relative to work authorized by this building permit application. Signature of Owner Date I, R 0Q�e - CIq r-- , as A�rreper/Authorized Agent hereby declar 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 e Ce4A1\. l — aif' ®/ Signature of /Agent Date • SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : RO�G - P. CA r 0 / 3/o License Number f3 e-k S'f' re , 130K3y Leeds At A, Dios-3 3/c Address Expiration Date /9-(% / Si natu Telephone :: �geistree`� I�`om :mrvementontra"ctor �- Not Applicable ❑ 204er e a/ark G-cn. Lnni. / 0/ 897 Compaliy Name Registration Number Address Expiration Date JP, Q , 'd) /C 3�� �edsJ'i11 , 0/�J Telephone (13's17//7d 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 affic will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ( No ❑ • Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act 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 then 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 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 • g4° ;i s1,1a ,t cr.i± >if Nazi E &ntptIxn __*_- W 4-1 y` i B lassxcaasctls' _"= '— W _ DEPARTMENT OF BUILDING INSPECTIONS =_ ' , 212 Main Street ' Municipal Building Northampton, Mass. 01060 r' : WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, 10- C/a k (licensee/permittec) with a principal place of business/residence at: q3 k S t: P D.Bo x3Y Leeds 4et, 0/&S3 (phone#) 'y/3—SAY J)7C (dtc t/city/state/ap) 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 working on this job: • (Insurance 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) if. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if neoe±ury to include information pertaining to all contractors) (►� 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 pm-sons to do r.mint.r,xor, coasirvctioo or repair work on a dwelling of not more than three units in which the homeowner resides or oa the grounds appurtanaut thereto art not generally considered to be employers under the work t'a a rnsation Act(GL152,3s 1(5)),application by a homeowner for a licasse or permit may evidence the legal status of an employee under the,Wodcc a Compensation Act. I understand that a copy of this statement may be forwarded to the Department of Industrial Aceida>ts'Oboe of Inaurnoa for the coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties 000sisting of a floc of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a , fine of S 100.00 a day against tux. 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