24A-024 (16) 89 RIDGEWOOD TERR BP-2002-0531
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-024 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: woodstove BUILDING PERMIT
Permit# BP-2002-0531
Project# JS-2002-0812
Est. Cost: $1200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 5009.40 Owner: VOSS PAUL& SUSAN
Zoning: URB Applicant: VOSS PAUL & SUSAN
AT: 89 RIDGEWOOD TERR
Applicant Address: Phone: Insurance:
89 RIDGEWOOD TERR
NORTHAMPTONMA01060 ISSUED ON:11/19/01 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL WOODSTOVE
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: � y��
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/19/01 0:00:00 252 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
Department only
City o4lorthampton Status of Permit:
-�-'�; i , $uildin6 Department Curb Cut/Driveway Permit_.
[_ s • 212 Main Street Sewer/Septic Availability__
r Room 100 • Water/Well Availability_
Northampton, MA 01060 Two Sets :A Struc:tuial Plans________
phone 413-587.12 0 Fax 413-587-1272 Plot/site Hans ._
Other Specify
APPLICATION TO CONSTRUCT, TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: 17G-y V 6 SS This section to be completed by office
�I )2 , �c�t d (/14 c 2.. Map Lot Unit
/1,/&, f l,� .—/� G v� ✓V'/J 0 06 0 Zone Overlay District
// Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
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
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection PJ—7- U O
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
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: '• L: ':
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:
SECTION5- DESCRIPTION OF PROPOSED WORK_(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 0
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 5)'s-jI INK' 0-GvQ"
Alteration of existing bedroom Yes /No Adding new bedroom Yes ��No
Attached Narrative❑ Renovating unfinished basement Yes �No
Plans Attached Roll ❑ - Sheet❑
6 Tf N MITOWeraMOditition�to earls#ing i uo singrowipiete `he fo11owin" :
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
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 proper
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ,�UL VO S5 , 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 pe Ities of perjury.
PG.,' I bss
Print Name
11ll � la�
Signature of 0 ner/Agent Date
•
SECTION 8--CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Regi °�terer1 1 2ifne i'mpr4vement Contrac or"», b _ A `61Persi 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 affidE
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
.1. 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 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)o the Massachusetts General Laws Annotated, you may be liable for person(
you hire to perform work for you under thi .e ' it.
The undersigned"homeowner"certifies d .• . es responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and .cal .•mg La an tate of Massachusetts General Laws Annotated.
Homeowner Signature /
•
i •
. �
5,04 Qs,
fl Gxtg xil Northampton n I =*=�
filansaclinactfa
DEPARTMENT OF BUILDING INSPECTIONS
• 212 Main Street ' Municipal Building
Northampton, Mass. 01060 ism
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
R Uo < 5
(lipermittee)
with a principal place of business/residence at:
(phone#)
(a ti cr t/ci ty/staleizi p)
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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiooil sheet afar+c,.ry to include information pertaining to all ooatadon)
( ) I3m a sole proprietor and have no one working for me.
( a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pasom to do w int.-from. construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto arc not.generally oomidcrcd to be
employers under the worker's nxrtpecnation Act(GL152,ss 1(5)),application by a homcowncr for a license or permit may evidence the
legal status of an amp loyer under the Worker's Compensation Ad..
I understand that a copy of thin ttatemast may be forwarded to the Department of Industrial Accidents'Office of Iuwranoa for the
coverage verification and that failure to secure coverago under section 25A of MOL 152 can lead to the imposition of criminal penalties
oonsisting of a fine of up to S1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a
fino of S 100.00 a day against tee.
For dcpsrtmeoal u'o only
l ✓�'�'�1 _� Permit Number
Mai{ Lot#
:*:-Y Signature o iccnsee/Permitter Date