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JUN 2000 J': �tasanrhncctta —'
PAR` MENT OP BUILDI�C INSPP.CTIONS —
([ �
?� ntn Strcct Municipal Duildinf,
....a.,_Worthampton, Mass. 01060 °
WORICER'S CO'NUENSATION INSURA.NCF AFRDAVT
-
% ith a pro-tcipal place of business/residence at
(sts�.t/ci t}'/statcf zi p) -- --
do hereby certify, under the painS and penalties of perjury, ?hat
( ) I am in employer providing the followins, worker's comocns:::jon cove—
ge for Inv
eluployccs wor!ang on Oils job
(Ilsu-r Corer ) (Pehc; N�aixr) — (r:Pircion Date)
I art a sole proprietor, general contractor o homeowner -cie one) a_nd have hired
the contractors listed below who have the foHo%V' P workers coffin n anon policies:
----
(I`+IIID: OI C ill-;!Ci0"�
(N,mc of Contractor) (Instrancc Comoan,,'/Po!ic',' `umccr) (-Lxp:lion Date)
(Name of Coaracto,) (Insurance. Compan)-/Pct q Numbu) (ENpimoon Date)
(Name of Contractor) (Insurance Company/Pohcy Numbs) (Expit-ation DaLc)
(coach:dii::ocaJ c`_xct ifn<�:.r;to ex!ucL mfcx n.:ion pertain r L eIj
sole propnetor and have no one working for me.
( ) I am a home owner perfofTmo all the work myself.
NOTE:plcs:be e roc 0-'u{-Jc bearrn Lets uto cmplay pc; w w i c -cu u oric ou.G..
o='t mxi clitang of
oni n-ore tJi.n 01 _Lairs or oo the pound]L;xputtrn—tbc� oo(Gc:�.-Ry oeci:d.--od to be
catployas und the .o i c{s axp�tim Act(GL15;,=1(5)�npptica000 by a homcoo-=fnt c tics_-e oc peril r>~y c.idmcc tLc
IegaJ eta ue of an--Ployor under dip Workcla Comte -Gou Act.
f uodmtand the a oopy of tbia may b°forvrnrded to tbo f A—do (0M oo of rot 1b,
c»vengc vaifirlim and t1--1 L-JvTC to coauc Covcta&C under"Cli11 25A of 1.(0 L 152 C.Ic d to the L,-oositim ofmm-1 p—llin
oomiriug of a dux of up to S 1-500.00 a"dIe)C o�rtso®x oCup W ooc yesr and o�iJ pmatLO m dx form of a Stop W--k Order and a
fits of S 100.00,dzy.piaA ax
For only --------------
VV// ✓
t D 0 Permit Number
Lot
Signature:of LiccnsccA'cmiittcc —� �-
Ct[at 8.:CClNS'CRUC7I�N'S1rRVIC S
}' A Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SCTIQN 111-"WORKERS"gQ"MPEM514TIQN,tNStJ�tANCE AF F113AVIT{M.G.4.c452,§25C
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...... ❑
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
No ampton Ordinances,State and Lo ing Laws and State of chusetts General Laws Annotated.
Homeowner Signature '2
le
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other']
� ��
Brief Description of Proposed Work:
Alteration of existing bedroom Yes_ No Adding new bedroom Yes t--fNo
Attached Narrative❑ Renovating unfinished basement Yes ✓No
Plans Attached Roll ❑ - Sheet❑
1:101 JiliddliVil:
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?
Type of construction
i. Is construction within 100 ft. of wetlands? Yes 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 74-OWNER AUTHORIZATION -TO BE OOMPI. TED WHEN
tiWNE pGENT.OR CONTRAOTOR.APPLIXS'l7OR OUIL ING PERMIT
I, 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.
Signature of Owner Date
� � - -
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 penalties of perjury.
—(v r o "
Print ame /
Signature of Owner/Agent Date
K
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 1V
Setbacks Front
Side L: R: L:-Z, R:
Rear /
i
Building Height
Bldg.Square Footage % a5-
Open Space Footage % �D
(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:
Dj Ci Northampton
.� 2 ul Department
ain Street
,� R om 100
t
NtrrtM ton, MA 01060
f
phone 413-587-1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
Thtt SE�G y
y Z
f
3
SECT-19N2-'P ROPERTY'"OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ro� cis,_ 0 U-e—A IC�CK PA
Name(Print) / Curr nt Mailing Address: ` �Q
Cn`p l%1 Q��
'Telephone
Si ature /
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIO4"3-ESTIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use O.nly';
com feted by ermit applicant
1. Building (a)Building Permit Fee
i
2. Electrical (b) Estimated Total nt Of
Construction from 6
3. Plumbing Buildi"n&"Permit Flee
4. Mechanical(HVAC)
5 it Protection
al =(1 + 2 +3 +4+ 5) Check Number
ff This Section For Official Use Only
Building Permit Number: � Y" Date issued:
Signature
Buildrrg
Date
Gornmissioner/Inspector of Buildings
File#BP-2000-1170
APPLICANT/CONTACT PERSON ROSA TONY D&ELSON
ADDRESS/PHONE 55 OVERLOOK DR (413)586-7171 Q
PROPERTY LOCATION 55 OVERLOOK DR
MAP 29 PARCEL 201 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: INSTALL 24'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,XOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co ission Permit from CB Architecture Committee
-?,- Lao d
Signature of Building OfKcial 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.
55 OVERLOOK DR BP-2000-1170
,GIs#: COMMONWEALTH OF MASSACHUSETTS
_y1ap:Block:29-201 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Above ground pool BUILDING PERMIT
Permit# BP-2000-1170
Project# JS-2000-2055
Est.Cost: $3200.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group:
Lot Size(sg.ft.): 16552.80 Owner., ROSA TONY D&ELSON
Zoning-:URA Applicant. ROSA TONY D & ELSON
AT. 55 OVERLOOK DR
Applicant Address: Phone: Insurance:
55 OVERLOOK DR (413) 586-7171 ()
FLORENCEMA01062 ISSUED ON.6122100 0:00:00
TO PERFORM THE FOLLOWING if'ORK:INSTALL 24' ABOVE GROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 Si nature•
Fee Tvue: Receipt No: Date Paid: Check No: Amount:
Building 6122/00 0:00:00 269 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building C:ornmissioner-Anthony Patillo