32C-214 (3) �. -
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12/05/2001 12:41 9782636276 GLENWOOD KITO-ENS PAGE 02/02
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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.
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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