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34-006 (2) i^ �ttAMpT. Grxf�ltltltlt � f _ 9 B �lassacifttnsctts' Vf ` DEPARTMENT OF BUILDWG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 '�•, s��` WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licenseelpermittee) with a principal place of business/residence at: (phone#) (strmucity/stawZip) r' a ;< do hereby certify, under the pains and penalties of pedury, 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) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following worker's compensation policies: m& 7C6-7 �. (Name of Contractor) (Insurance Co /Policy Number) (Expiration Date) .,, •CJ�t�lli./I'�L �iW'Ls' T���Q.,..�.� /3G17 Tai 3&'Cti15 � 1 4 (Name of ntractor) (Insurance Compaay/Policy Number) (Expiration ate) (Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attack additional short ifnecensry to include infocm.tion pertaining to all ooatmcton) I am a sole proprietor and have no one working for me. ( I am a home owner performing all the work myself. NOTE please be aware fiat Amlo homeowners who employ pasom to do mat denaaoe,congriction or repair work ou a dwelling of not afore than these units is which the hon%wwaer ratites or on the ground:sppurteaantthacto=not generally wandered to be employers under the wm*a's compeas4m Act(GL152 m 1(5)1 application by a homoowwrr for a license or permit may evideaw the legal staum of an employer undertbe Worker's Compenaatioa Ace. I understand that a copy ofthis stitemmt gray be forwwded to the Departmm2 of Indwfrial Aocidmtd Oflief of lanes aoa for the oowxage verification and that failure to loam cowmV under secflm 25A of MGL 152 an lad to tba"imposidoa of criminal pemlties oomitting of a fine of up to$1,500.00 andlor imptnoamcrA of up to one year and civil pemttia in the form of a Stop Work Order sad a fine of S 100.00 a day against tat For dqmW=W use aaty permit Number Lot# Signature of LicenseetPermi SECTION 8-CONSTRUCTIQN;SERVICES r 1 Licensed Construction Supervisor: n n Not Applicable ❑ Name of License Holder :-/?j G Tl/'�/7 L2 /3 o,/A/D 0 -a a 67 License Number OX FA5ryA1--A PTO-Al 6 Address Expiration Date Signature Telephone [ Not Applicable ❑ Company Name Registration Number Pa Address t Expiration Date 0/0--27Telephone-64r6 S � 5,ECTION 1 -WORKER$'COMPENSATION INSURANICE 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. igned 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 Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature - DESCHI TI N OF eROP§;1Q' `QRK(-check,all anfiahUe, New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: V 41 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 01, y. 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? C d. Proposed Square footage of new construction. 7qQ _Dimensions er, G ' e. Number of stories? i f. Method of heating? Fireplaces or Woodstoves_/X40"" Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? Type of construction gveM4 i. Is construction within 100 ft. of wetlands? Yes —)(—No. Is construction within 100 yr. floodplain Yes A—No t 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 S CTIO.N DWNER"AUTHORIZATI.ON -TO 13E COMPLETED WHEN QWNI"RS AG' GEI+Ir'T OR CONTRACTOR"APPLIES F'QR-BIJILDIN[6;PERMIT Pic 9/4/?.D Gay%-1D 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 10, Signature of Owner tate 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. 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 134 0 �j - Frontage Setbacks Front / 0 Side �;� �R: � L: R: � O Rear J d Building Height Bldg. Square Footage (y� % Open Space Footage ,?.}D/ ^ % (Lot area minus bldg&paved /,�S(s 4,x.,�3 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 fr m 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: Northampton Building'Department MAY 1 5 20012 M Street R -om 100 t _ tyth,ar+a�ton MA 01060 0hone 41 $ 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: "RIX s ` x fit`tls#rIC SECTION 2- PROPERTY OWNERS IPIAUT14ORIZED AGENT 2.1 Owner of Record: 67/0 7 91 02 8—e—P,V,D 80 BOX ef6 EA5TIMAA) 0A1 Name(Print) Current Mailing Address: Telep hone Signature 2.2 Authorized Agent: Ida Name(Print) r Current Mailing Address: Signature Telephone SECTION'S ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a) Building Permit'Fee 2. Electrical , ��CJ (b) Estimated Total Cost of Construction froho 6 3. Plumbing S O O Building Permit Fee 4. Mechanical (HVAC) tL 00 5. Fire Protection gy 6. Total =G + 2 + 3 +4+ 5) / Q ,G7 fl Check Numbers This Section For Official;Use Only Building Permit Number: Date Issued: Signature: _ Building CommisMoherl#nspector of Buildings Date File#BP-2002-0990 APPLICANT/CONTACT PERSON BOND RICHARD A ADDRESS/PHONE P O BOX 86 PROPERTY LOCATION 276 TURKEY HILL RD-LOT B MAP 34 PARCEL 006 001 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONSTRUCT SFH W/ATT GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 022674 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKE ON THIS APPLICATION BASED ON INFO ATION 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 S 3o zo�2-- 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. >*rr+- fQ w Ono Wo Gov wommys c m ;}.ta �' s ''�,ti='c * ?,�yy „�a$£•' k� ~ cs * '� '�.�s e .,.; # rn,•.. { v a 'y'' -E S`' ¢},d '? , r , f= :T 2 .a, y„se.3 is ,� € a town `: try �20 't� r�4x� '"x i �s�, .«r• v "� t v� firo�'�°a s. �,-�t:. _ a '�. A �. �`' � ,,.�� `� a -«yg � r ��" �r�'.Ytt xr -mumm not a ON t r m x ? � � a 3` VV e '. 276 TURKEY HILL RD-LOT B BP-2002.0990 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Bl .: :34-006 CITY OF NORTHAMPTON Lot -001 Permit: Building Cateaorv: BUILDING PEMIT Permit# BP•2002-Q990 �'roiect# JS-2902-1603 - F,st.Cost:$1 IM-00 Fee:$820.80 PERMISSION IS HEREBY GRANTED TO coast.Class:5B Contractor: License: use • `4 RICHARD BOND 022674 of S" ): 41643.36 Q"er: BOND RI(MAM A Zoning:R Jpgrgant: BOND RICHARD A AT: 275 TURKEY HILL RD - LOT B Annlicant Address: Phone Insurance: P 0 BOX 86 EASTHAMPTON MAO 1027 ISSt�ED ON;513LIO2 Q:00 0© TO PERFORM THE FOLLOWING WORK.-CONSTRUCT SFH WATT GARAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground- Service: Meters Footings Rough: g �"" Rough:` (I-I j C^N House# Foundation: Driveway Final: ✓, ,� Final:/j/l '�t nal Mtt�lm�r •, Rough me; _.-- Gas:&4 / . h' DeoBrtn nt Fireplace/Chimney: Rough: Insulation:( k' of 770112 Final: , NI e: 61 IC Final:,K JAM ISA6 THIS,PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF ANY OF ITS RULES AND REGULATIONS. .... Cgrtifigate of 0 r Fee T z Receipt No: "'ba e Paid: !Q Wk No ''mo ut: Building 5/31/020:00:00 1799 $820.80 212 Main Street,Phone(413)$$87-1240,FaX:(413)587.1272 Building Commissioner-Anthony Patillo