34-029 (3) p E w
JUL 12 4001
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON,MA 01060
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m DEPAR7VENT OF BUILDIT;G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AI+I+IDAVIT
(Ii ccr>_secJpermi tire)
with a principal place of business/residence at:
N t A\
(strc i/6ty/state/ziP)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverge for my
employees worldng Uri this job:
(Insurance Company) (Policy Number) (Expimtfon Daze)
I am a sole proprietor, general contractor homeowner (c le one) and have hired
the contractors listed below who have the following wor e s compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expimtion Date)
f.
(Name of Contractor) (I.nsurance Company/Poiicy Number) (ExTp ration Date)
(Name of Connacter) (Ir)zlurance, Comlh"_UY/Policy Nurnikr) (Ex,iration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifmccnAry to include inform .pert4lnnr to all wat r')
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptease be aware that wtzilc bomcowncrs who employ pc. : to do mx jrj�oQ:rsm=oo ar repair work on a dwelling of
not morn than throe unit in which the hom,�owncr miidcs oc oo the prouads appurttnant therto arc no(generally oomidcftd to be
employers under the wvfktes coo;xa on Act(GL1 52,=1(5)),appticabon by a homcow=for a ticcase cc pond?may cvidcacc the
legal etahu of an amployoc under tho Workoet Compensation Art_
I uaderatand that a copy oft"rtatcmmt may be forwarded to the Doparm of IndzLS d Ac6d.&otuoa of]nwrwco for the
coverage vaifiadioa and that fail=to scc=covaago tinder s-ion 25A of MGL 152 can toad to the imposition of criminal pcaall:cs
oomisting of a fine of up to S 1,500.00 and/or impris�of up to one year and civil pmattia in the focm of a Stop Work Ord--and a
fine of 5100.00 a day sgaiast mc_
For dgwtnr W uao oaly
. permit Number
hbP{ Lot tt
Signature of Licensee/permittce e
SECTION 8 :CONSTRU,CTION,S;ERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�Reeistered=HomelitiproveinentCo�tractor "'a Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 affidE
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached ]C— No...... ❑
f
�o`meO�w.ne xempt�ori
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(.
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 hampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION5' DESCRIPTION OF:PROPOSED WO
Recheck all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. X Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑. Sheet❑
sa,Jf New Fiotise.and=or`addition'' oexisting-liousi`ng, co'mpleteAhe followi j; :
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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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 OW'NER.AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS3AGEN7;".OR CONTRACTOR''APPLIES FOR:BUILDING PERMIT
as Owner of the subject proper
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
l 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 enalties 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
�j Building Department
Lot Size i / T
Frontage
Setbacks Front 0
Side L: R: L:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(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 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. Ar there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
f
«, fie artrrfe use ) F A
t f Northampton States otyHermit �" ' � i
JUL 2 2001 ing Department Curb�Cut/ r+vewa ,
21 Main Street Sew"er/SepticA
oom 100 Water JWel Avaaiabtiity
DEPT OF BUI101NGINSP010, �rtha ton MA 01060 TwokSets ofi Structural Plans �$
NORTHAMPTON,MA OIO6bb�v P � .
e -1240 Fax 413.587-1 272 Plot%Site Plans ate, 4 � N N V�x
Other Specify x � �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
i.l Property Address:
This section to be,completed by office,
Map Lot Unit
Zone Overlay District
Elm St.District_ CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/Jl)RZE GLC_
Name(Priint), Current Mailing AddreL
_ W, ?eieph—on e ? 3�
Signature
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
Building ( C) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 + 4 + 5) Check Number �-
This Section For Official Use Only
Building Perm it Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0045
APPLICANT/CONTACT PERSON BELL ANDRE
ADDRESS/PHONE 120 TURKEY HILL RD (413)585-9035 Q
PROPERTY LOCATION 120 TURKEY HILL RD
MAP 34 PARCEL 029 001 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: ERECT 16 X 12 SHED
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF30RMATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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
1,12/J2-
LOO
Signature of Building bfficial 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.
BP-2002-0045
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Category: shed BUILDING PERMIT
Permit# BP-2002-0045
Project# JS-2002-0059
Est.Cost:$3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.)_ Owner: BELL ANDRE
Zoning:RR Applicant: BELL AN D R E
AT: 120 TURKEY HILL RD
Applicant Address: Phone: Insurance:
120 TURKEY HILL RD (413) 585-9035 (�
FLORENCEMA01062 ISSUED ON.71121010:00:00
TO PERFORM THE FOLLOWING WORK:ER E C T 16 X 12 S ED
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/12/010:00:00 2472 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo