32C-302 (3) R `e v.ii-�) of �,To fIJUIIIPtoil �=
�tasanchncrtla - � _
u DEPARTMENT OP DU!(-Dr>\G INSPeCT101.'S =
212 Alain Street ' Municipal TBulld nP
Northampton, Mass. 01000
\'ORDER'S COMI'ENSA'nON LNSURA-NCE :1hI,LDAV17'
(liccus:rJperinittcc) _ _ —
\r.-iLh a principal place of buSIaCSS/rcSldenGe at:
(stTr�tici ty/stalcTa p)
do hereby ccrtifj;, under the pailLs and penalties of perjury, t}lal
( ) 1 am an employer providing die following worker's colnne Ss:10n cove 2gc for my
eruplovccs wor,Dng on Lim job.
(tnsur Corsr�.) (PeUc; Nu r) Date)
a-m a sole proonetor, general contractor or o'meow-ner ucie one) aid have hired
the coosactors Listed below who have the followt�Q workers co��ens2aon policies:
(Naru¢io�Conl:aclo;l (Insunnc;, Colnpan}'fPciic; ?�'tun'cc;) (i_�)l;duon D�lc)
(N; e of Contractor) --- (tnsuanCc Comoaa`•/Polk-• Numcrr) (xpiM.iion Date)
(Na-me of Connacto,) (Laurancz Compan)/Poticy Numb`r) (Expiraon Datc)
Mi -Mc of Contractor) (tasZ Fmc;� CompaM,/Poticy Numbs) (Lxpiradon Daic)
tafcrn oo P-A iaing to.L oo.r.�o�)
( ) I am a sole propnetor and have no one worljog for me
( ) 1 am a home owner performing all Lhe work myself.
NOTE:pl=s tY awy<tFj a. l Jc hcarA. ,ba cuiplay pc ow uo w c �aac�, c rrpu..orx ou.d..c1L g of
a.ot axYt tr._a t`-rc.-. a in u',tich ttx twcmo-..vcr rt-do o<oo the p-ouod,zpputicrt�rl ibcc'.o�T Doc -ter.-:=11y arc,: �c i to t-
«tployc z un_ h .ai dz ccm�um Au(GL152---�1(5)�application try a bomco,u fm bc::2-cc pe'mit ray c 16 occ trc
Icg>1 ctaau of an czhloyx under dro W.,k e,Coa�xm.t_ioa AcL
I uad-,i d thn> on of thi,cx�may tx foa-x�v clod to tbo pc-putmcrit of In¢.�ri al n_dns�OtL_of lrwz�o�for ttso
coven&C vcrif elioa am that U- Lm to sauce OvcT"a C ux)dcr soetioa 2 5 A of M()L 151 can Iced o Lh, on of enmicA PcOl Wa
co"'L" g of a Goc of UP to S 1.500.00 andfor izpxi}oanjc t or up to Doc yc cod 6Ni1 pcc_,pL.in d,form or a Stop Wmk Ordcr and a
fim of 5100-00 x day xEatasl me
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
-----------------------------------------------------------
Signature Telephone
9. Registered Home Improvement Contractor. Not Applicable ❑
------—----- --—--—- —--—------—--—--— --
Company Name Registration Number
X5 ------------------
Address Expiration Date
'� A----70�41�- -&a
-,VPC-E.Telephone Y13
717-------
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....... ❑ No...... F-1
11. - Home Owner Exemption
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 Si 1,414 Au.,-
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 he filled in by
/ Building Department
Lot Size
Frontage 75'
Setbacks Front D 16-
Side L: R: L-� R.
Rear
Building Height
VV ANy 0 20
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved 2
parking)v
#of Parking Spaces ?" V N
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO —Z DONT 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 tJ any proposed changes to or additions of signs intended for the property?YES_
No y
IF YES, describe size, type and location:
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ I Replacement Windows Alteration(s) ❑ Roofing ❑
('�1` Or Doors ❑
Accessory Bldg. ❑ Demolition❑ v New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description gfof / N�Work: fF� F_ oD
/ /
Alteration of epsting bedroom_-----Yes_1_v No Adding new bedroom - Yes _— /
Attached Narrative Renovating unfinished basement ____Yes Yes _ _No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing housing, complete the following:
a. Use of building :One Family---4Z_ Two Family -----Other—__—__
b. Number of rooms in each family unit: Number of Bathrooms__.
c. Is there a garage attached? � r"e _
d. Proposed Square footage of new construction. Dimensions z � 5
e. Number of stories?—_ ------_-_ --_--
f. Method of heating?__ - Fireplaces or Woodstoves_____ _-_Number of each
------ --------- — J� --
g. Energy Conservation Compliance.__---__—__—__—__Mascheck Energy Compliance/form attached?_ -"--_—__-
h. Type of construction------------—
i. Is construction within 100 ft.of wetlands? Yes Y 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.
------------------- — -----------------------------
In nature of Owner Date
7belief. N1V1f-__!!vimf _—_ as Owner/Authorized
reby declare that the statements and information on the foregoing a plication are true and accurate,to the best of my knowledge
Signed under the pains and enalti s of perjury.
7PrintF;. - -------------------me
--- D_v I-VI-VA-1 A-1,1*-IA)J,-__0At71_e- VK d 2) It
Signature of Owner/Agent Date
Department use only
I f Northampton Status of Permit:
u I 'ng Department Curb CuVD&mway Permit
�! I Main Street Sewer/Septic Availability
JUL 1 6 2002 oom 100 Water/Well Availability
N rtha pton, MA 01060 Two Sets of Structural Plans __ ____
- -�I -587- 240 Fax 413-587-1272 Plot/Site Plans
0ii F B�ItCl4 �s W60 Other Specify
LICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot--300- _—Unit___—___
1 �( �, nt zwzf Xaw- Zone_ _Overlay District-----------
Elm St.District-- CB District_ __
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name rint) Current M fling Add r ff
--� y '"3 4 /----------- -
_ Telephonek3
nature z/
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 $ ? 7 (a)Building Permit Fee
l
2. Electrical (b)Estimated Total Cost of
Vv Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number J 9 �S
This Section For Official Use Only
Building Permit Number: � `�S Date
Issued:_—__—_ _
Signature: _—__—_
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0055
APPLICANT/CONTACT PERSON WILKINS-CARMODY DONNA
ADDRESS/PHONE 17 VALLEY ST (413)584-5366 Q
PROPERTY LOCATION 17 VALLEY ST
MAP 32C PARCEL 302 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERM_ IT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid S-
T_ypeof Construction: INSTALL 24 X 15 ABOVE GROUND POOL
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
INFOI�JMATION PRESENTED:
pproved 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 Co *ssion
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.
r r
�T BP 2003 0055
GIs#: COMMONWEALTH OF MASSACHUSETTS
33 .-362 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Above ground pool BUILDING PERMIT
Permit# BP-2003-0055
Project# JS-2003-0135
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor—
Lot Size(sq.ft.): 6490.44 Owner: WILKINS-CARMODY DONNA
Zoning:URC Applicant: WILKINS-CARMODY DONNA
AT. 17 VALLEY ST
Applicant Address: Phone: Insurance:
17 VALLEY ST (413) 584-5366 ()
NORTHAMPTONMA01060 ISSUED ON:7118102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 24 X 15 ABOVE GROUND POOL
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/18/02 0:00:00 593 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo