18D-053 80 DAMON RD#6302 BP-2001-0617
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-053 CITY OF NORTHAMPTON
Lot: -156
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0617
Project# JS-2001-1099
Est.Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AWL MAINTENANCE SERVICES, INC. 129175
Lot Size(sq. ft.): Owner: GANDHI CHANDER&ROSY UPMA
Zoning: GI/WP Applicant: AWL MAINTENANCE SERVICES, INC.
AT: 80 DAMON RD #6302
Applicant Address: Phone: Insurance:
P O BOX 865 (413) 529-1936
EASTHAMPTONMA01027-0865 ISSUED ON:1/8/01 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE TUB & TILE FLOOR
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 1/8/01 0:00:00 2761 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
File#BP-2001-0617
APPLICANT/CONTACT PERSON AWL MAINTENANCE SERVICES,INC.
ADDRESS/PHONE P 0 BOX 865 (413)529-1936
PROPERTY LOCATION 80 DAMON RD#6302
MAP 18D PARCEL 053 ZONE GI/WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Fee Paid 0176/ —
Typeof Construction: REPLACE TUB&TILE FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 129175
3 sets of Plans/Plot Plan
THELLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
J 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 Comm' ' Permit from CB Architecture Committee
00/
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.
M
}
C V Department use only
i l 4of Northampton Status of Permit:
(ding Department Curb Cut/Driveway Permit
,..\\ jivi 4 .12 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
DEP'f OF BUILDING ItmSPEArthampton, MA 01060 Two Sets of Structural Plans
r� ' S�TON h�l
mm --( one33-587.1240 Fax 413-587-1272 Plot/Site Plans
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 Pro ert Address: �1 �) -
l0./ ve (-4--A-)Z (4--� l d ,'�c4�U 4,-,/, ,-4--+-� Map Lot /Unit -)
to 11C,'t---C.1 A) f v(Q t ), �-�I J�� _ 0 Zone v Overlay District
/� c7 Elm St. Dis rict CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: a
CAa Je' 04CC M j
"nme(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: ,, P y
Name Print) Current Mailing Address: 0`0?.
��7 — 702 ,E
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building . (-'(3 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing le) ; ° .._.--c Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number di(p( '50 ---
This Section For Official Use Only
Ruilding Permit Number: 6' (7 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings 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. Are there any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
:CTION 5- DESCRIPTION OF PROPOSED WORK(check al! applicable)
New House 0 Addition ❑ Replacement Windows Alteration(s) fie/ Roofing 0
Or Doors 0
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom . Yes No Adding new bedroom Yes ✓ No 1
Attached Narrative jam Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a a*house and'or addition:t".. .xtsttl #tat tn> ompi c g o,o
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?
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
, 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
, 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.
igned under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
4.
cFCTION 8 -CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable 0 ed Home i,.v�,.m . . _ u�..,, . . _ pP �
Aw - tfa ilitet..074 ce Vice_; /c19' / 23
Company Name Registration Number
fo dx* ?6 j •-•/9 — of
Address 1 /� �` / Expiration Date
S , aft-p!'O1A) / /a• O�°y elephone �a/ —/Q3ty
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.
"igned Affidavit Attached Yes ❑ No ❑
11 . Homebne
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
.
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2 DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 _".
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L A i C-c S I✓,c,e,E
___Im.4_ ,
(licensee/permittee)
with a principal place of business/residence at:
(phone#) �b` —1 ��
(s ti eet/ci ty/state/ri p)
do hereby certify, under the pains and penalties of perjury, that:
( am an employer providing the following worker's compenc lion coverage for my
employees working on this job:
L, `, M - -a. L / —as'- of
' ce Company) (Policy Number) (Expiration Dale)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
1t
(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 aciditioctd sheet ifneri-n.ry to include information pertaining to all ooatractors)
( ) 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 persons to do maintentDr•,construction or repair work on a dwelling of
not more than throe units is which the homeowner resides or oa the grounds appurtenant thereto are not generally comidcred to be
employes under the worker`s ofelpr.oxtion Act(GL152.ss 1(5)),application by a homeowner for a keener or permit may evidence the
legal atatua of an employer under the Waiter's Compensation Act.
I understand that a copy of this statement may be forwarded to the Depe in w2 of Industrial Aceidmt Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 an lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
film of 5100.00 a day against me.
For departmental use only
r-2z-i r y Permit Number
1p Lot 4
Signature of Li ermittee Late
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