12C-080 (7) I
�o
1
ti
�o
a' x� f �y• � �' f x'
i
IL
Ca y , w� •
••
i
ter„ /
tb
� bt�r
i
1
�4
y
t
f
k
Id
w�
r
i
S x I
W �
U � �
r
U
� 1
� � I
i
i
I
i
a 4
J�
� N �
> o
"vfQ
i
z _
/ � o
Y '4--p
x
� x o
Y ol ✓ perp,� n a
p
b�; b
i
� I
d
i
' I
• -/+��r 6tt /
y
� I
r
kb
� a, r
th
t
�2
6
11g,A�•t/'
CO
I
` -�t1IJ'fPT
COQ�4t,p O e
e a Cr I cxf crz#f��zlil�tLtli
9 9 f�lasaxchnsrtts
DEPARTMENT OF BUILD0\7G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION TNSURANOE A IFIDAWT
(li censerJpenn�flee)
with a principal place of businessJresidence at:
-(phone#)���.�
t city/stafrJzip)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following ,,vorker's compensation coverage for my
employees worming on this job:
(Lnsu=cn� Company) (Policf Number) (Fxpirarion Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Con pang/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F-•piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additice-d s}u i ifnoccTzuy to include iofornufioa pertaining to all ooc radors)
(►�1 l am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awzrc that while hom owvcrs who cmplay periom to cis rn–aintcnince,corr;rucLlm cr repair aork on a dN%T-L rig of
not more tli:n threo units in which the homeowner r)=dcj a oa the pounds appurIcnauI thereto arc act Lcncrally coasidcred to be
cmployas under the worlcr-t's compc=4ca Act(GL152,=1(5)�aryUcatien by a h.,A-ci for a license a permit may cvidcnn the
legal rtanrs of an omployor under tho Workoeg Compomatioa Ac-
I understand thst a copy of this ehtcmcut may bo forwarded to tbo Dcpartmco2 of]ndaa%bial Ac«ae'=&Offroe of I-ucaoco for the
coverage vatficaiioc and that failure to&own covecago under soctioa 25A of MGL 152 can lead to tho imposition of alminsl penalties
ooatitti t eta frnc'of tip to S 1'500.00 and/or imptisoaax zt of up to one year and civil pcmltia in tic focm of a Stop\Vote Ord--and a
find oC S 100.00 a day against me
Foe dcpa�u'o ealy
. � Permit Number -
_O Lot
e
r Si f Li c tree
SECTION 8-„CO?NSTWP,TIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
K'f e ff ter`r d,eTl� +r."��xa M—' ..- -:,.w-�e..-ra+�xt.,Yi�yv d�,{��' ��� Y tt���e 1{, :'”'
m r. vemen ,Contractor ,, •�y,�-��,��„�;,�,;;��t���,�,,;�;,x� , � s;i� �_ Not Applicable ❑
Company Name ZJ ,del Registration Number
c7y
Addr ss — 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....... 0-- No...... 0
on One emp: l`o n
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' Com jensation) 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
e '
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing C1
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ t ( ,t,jew Signs [ ] Decks [r ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
"j / < ��,A �.
Alteration of existing bedroom Yes _ No Adding new bedroom Yes '—1 No
Attached Narrative 11 Renovating unfinished basement Yes i-----' No
Plans Attached Roll Sheet ,r
6a.'If�New=
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 In
Setbacks Front
Side L:> R: L:X__R:
Rear , v
Building Height l
Bldg. Square Footage % ;
�G?O
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 G`f 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 ere any proposed changes to or additions of signs intended for the property ?YES _
No
IF YrS, describe size, type and location:
City of Northampton S�at"s°of P `f
Building Department Curb C
212 Main Street Se, r75e
Room 100 Wa er/We v ,
Northampton, MA 01060
phone 413--587"1 VO Fax 411587-1272 PIotIS e
Other",Specs �'�
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. ri
Map Lot Unit
Zone �,�_ Overlay District
Elm St. District- CB District
SECTION 2 - PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
--��-��•�" G �"�C,'"J�'1:.� l/ �t!!! y..^�_;_ �i�?,���y�Titer- /� �:/�•
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized A nt:l
Name(Print) Current Mailing Address:
Sig ature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee'
2. Elecirical (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) / Check Number SD1
This Section For Official Use Only
Building Permit Number: , Date Issued:
Signature:
Building Commissioner/Inspector of Buildings_ Date
File#BP-2003-0485
PPLICANT/CONTACT PERSON Kent Hicks
ADDRESS/PHONE P O Box 119 (413) 238-0122
PRA
k
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REBUILD EXISTING 17 X 9 PORCH TO I T X 6'
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 066104
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PP
SENTED:
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: § ?3 4,
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 C mission
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.