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32C-214 (3) �. - 3 � 12/05/2001 12:41 9782636276 GLENWOOD KITO-ENS PAGE 02/02 1 �± JAN - ? 2002 ;�, i i 1 10 z UJ u. 9 ~ SI { R 1 1 1 ep. � iL. ` 4CYtA11P�O 9 fl Git J Jaf wart 4aillp foil i3Ett Cll ltSClta DEPARTMENT OF BUII.Dr NG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFEDAVIT 1, (licensee/permittee) with a principal place of business/residence at: (phone#) (streei/ci ty/st afr/a 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) (VIKI am a sole proprietor, general contractor o homeowner(circle one) and have hired the contractors listed below who have the following wor e s compensation policies: 616 0 d e (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) (Name of Contractor) (Insurance CompanyRolicy Number) (Expiration Date) (-Hach additioasl sheet if nwc=L Ty to inehsde iafvcmafioa pertaining to&B c,:-=MCtors) ( ) I am a sole proprietor and have no one working for me. ( ) X am a home owner performing all the work myself. NOTE:pease be-wain that whilo 6omrAwncn who employ pazoas to do umintenxacr coasuuct on or repair wociC ou a dwelling of not more than three units is which the homoowocr rc=dcs or on the gou,,ds appurtenant th=w arc not&cna-2-ly oo=dcrcd to be employnn user the worker's compcas4ca Ad(GL152,mi 1(5)),appti.cation by a homcow=for a license or permit may evidence the ltgil ctatua of an employer underthc Wociceez Compca& a a AcL I understand data copy of this rtatcmmt may bo forwarded to tho Dcpartmco2 of Jn&Lthial A c6d=&omoo of Insursnca for the coverage vrrifiauioa and that Ed=to aecuro coverage under sxtion 25A of MGL 152 can Imil to ibe imposition of aimiasl peaal - oomistiag of a fine of UP to S 1,500.00 mrWor imprisonment of tip to one year and civil pemati a in the form of a Stop Work OrdG and a firmofS100.00*.day ag&inst mt For depzr1me1al use oaly permit Number u'1a,A tin/ 1 _ /- (�/ Malt Lot# bi&Uatdc of Licen,SeeNcrtn um Date it SEGTQ 8 CONSTRUCTION,SERVICES 8.1 Licensed Construction Supervisor:/ Not Applicable ❑ 'I Name of License Holder: 0/on ale 131COk 6 313 3 7 (v License Number /o - 1r — a3 Address Expiration Date Signature Telephone en ,,M r Not Applicable ❑ rr_337_3 Company Name Registration Number /,- f-,4 3 Address Expiration Date Telephone SECT�ION10-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...... ❑ 1 a' � some 00 WAVE e� 1016nr 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 persons) 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 i,MN, C)- yu SECTION':53 D CRI �O'I ROSED INOR ch`ec all,:a licable , 3 q KA3.. .. t .._. _ ...SRN 3. MME '.�•=,!M. ,fiTR .., h. :,.,£,,l 3,a> i+33,r�"YY: New House ❑ Addition ❑ Replacement Windows Alteration(s) l� Roofing ❑ Or Doors L>}-' Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: ktirh61 M n00 C,1 Alteration of existing bedroom Yes ✓No Adding new bedroom Yes 4— No Attached Narrative 0 Renovating unfinished basement Yes � No Plans Attached Roll 0- Sheet 0 li a ho se to o tl'ditro-rrk o exis WhouTMJ �cWm [ t fiot=ldVM F p ' a. Use of building : One Family �� Two Family Other b. Number of rooms in each family nit: 3 Number of Bat ooms t c. Is there a garage attached? d. Proposed Square footage of new constr tion. Dimensions e. Number of stories? f. Method of heating? f Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 f of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or IIar floor below finished grade k. Will building con rm to the Building and Zoning regulations. Yes No . I. Septic Tan City Sewer Private well City water Supply SECTION 7a-.OWNER=AUTHOR,IZATION -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. 3 -6 a Signature of Owner Date I,— Cil�/�E� C c/c�C✓�dS as Owner/Authorized Agent hereby declaTre 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 Signature of Owner/Agent 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 1 % Open Space Footage % (Lot area minus bldg&paved parking) #of Puking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Find ding 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 V' 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: L C �C rthampton i— Department ' 1 I 2 Ain Street JAM - 3 2002 100 Northampton, MA 01060 Fax 413-587 1272 y APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION-1 -SITE INFORMATION 1.1 Property Address: a This sectio o b oompteth R �YP�f Map � .f���,L t om; c1 U MCP �� S ,1��hG•�''O>o0 Zone Overtaji District � � EIm.S CID istrict' 4CB is r�ct ,.. _ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED;AGENT 2.1 Owner of Record: J'/' n c /V 13 �X 15-1-3 Nam (Print) Current Mailing Address: -ski 3 516" - 9 S97' Telephone Signatur 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 ermit applicant 1. Building (a) Building Permit'Fee 2. Electrical (b) Estimated Total Cost of �� �U 3 , 066 R�� Construction from 6 r 3. Plumbing Building Permit Fee i d CbC.S . 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This.`Section For Official Use,001 Bullding•Permit Number: Date Issued: " 33 Signature Date w ,,; Building..Commissioner/Inspktor�of Buildings File#BP-2002-0618 APPLICANT/CONTACT PERSON EDWARDS LYNNE ADDRESS/PHONE P O BOX 1513 (413) 585-9897 Q PROPERTY LOCATION 35 HOLYOKE ST MAP 32C PARCEL 214 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out _ Fee Paid T_ypeof Construction: REMODEL KITCHEN&BATH&SILL WORK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF0,161ATION 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 Commis 'on � Lad L 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. Y3 F y } } how owes A put w„ P � 4 a �a rr µ x low_ Kamp PIECE r a � r` w u 1 ,r 4n :� c too Woo to WE m s !,jaw non into son AnT a ZA My S-00 SON { # r ` �5 ROM r MATT IQ TM not was WSTA i dY ?. Z f` 4 c MMM NS MW ENO at, Ong MY tr s [ t t t 5s 04 a4 still;I 35 HOLYOU ST BP-2002-0618 GIS# COMMONWEALTH OF MASSACHUSETTS Ma :B cck:32C-214 CITY OF NORTHAMPTON Lot:-001 P91i: Build i nR Categoy:Non structural interior renovations BUILDING PERMIT Permit# BP-2002-0618 Project# JS-2002-0963 Est.Cost:$36000.00 Fee:$120.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot%ze(sq.ft.): 3789.72 Owner: EDWARDS LYNNE wing::URC Applicant: EDWARDS LYNNE AT 35 HOLYOKE ST Applicant Addr Phone: Insurance: P O BOX 1513 (413) 585-9897 n NORTHAM PTO N MAO 1061 ISSUED ON.117102 0:00:00 4 TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & BATH & SILL WORK 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:'w�%;`M�� House# Foundation: 4'e v Driveway Final: FinaL•s Final: Rou g h Frame: k Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Final:®� THIS PERMIT MAY BE REVOKED BY THE CITY NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupangy Occupancy Si nature. Fee Type: Receipt No: Date Paid: Check No: Amount: Building 1/7/02 0:00:00 101 $120.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo