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29-201 a 9 a�i z . Fil JUN 2 1 2000 (� ' r 1 ! 3 , f cis f f s Iii ��tv trnT It- ) of ATIDIAI a111}�toII a — _ - 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