35-222 (3) 2�
U,
JUN 7 2002
DEPT Of BUILDING INSPECTIONS
NORTHAMPTON,MA 01,060
1,a7l
i
4-�IiAMPTO
t'O a
s fl Gf it r of wart 11 llytoll z
�aSIIFCI�ttSrlla
Y
DEPAR7VENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, I41ass. 01060
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
(Ii censer/perm i tt ce)
with a prirtci-pal place of business/residence at:
(str�ticity/suer zip) �����
do hereby certify, under the pains and penalties of perlw-y, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insuranoe Company) (Polio Number) (Expi r-ation Daze)
( ) 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'.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insulrance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insu mn� Company/Policy Number) (Expiration Date)
(Name,of Contractor) (Insurance Company/Policy Numb(-,r) (Expiration Date)
(a71a-m on'l slh-c t i£ntc +-y to include infonnsti on p=tainiag to nil coa4ntiors)
( a sole proprietor and have no one working for me.
( ) I am a home owner performing all the wort; myself.
NOTE:please be await that while homcownetz who cmplay pazom to do maiatcaancp,oc,— ion or repair w'oric on a dwelling of
not more than three traits in which the homeoavcr rtsid-:3 or oo the g ourbds appurtenant tlbcr t ere oot gan r y oomidcrtd to be
employers undcr the veor &s ccutpessation Act(GL152,s 1(5)),a pplicaion by e hommwar for a Been=cc permd may evidence the
ItS21 etatzre of an employer under the Woricads Compomaiioa AcL
I understand that a copy of thin czntcmcat may bo forwarded to tho Dgwtmccd of l-&.rW Arcidm&Offioc of Imur+oco for the
coverage vaif'artioo and that failure toðic coverage under soci%oa 25A of MOL 152 can lead to the iutpositioa of criminal pcmltica
--isting of a fine of up to S1,500.00 and/or impr sot>mctii of up to one ytar and civil pcmltia in the form of a Stop Work Orden and a
fl=01 5100.00 a day✓agaiasl me
i
Er
1
use&Tsrtm dst ao only
' ,! I Permit Number
.I,EG.; Y Loth
--> �
Signer of Liccntrr/Pcrtnittcrt
SECTION 81-:CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
i' f
r^ ;
d
Addr s Expir tion D
_ ,, - _
skoa.t e- Telephone
v`
9 W`Registered Home lmpro inent Contractor:' Not Applicable El
:
6rnpanyW arne Registratio Number
Address Expir tion Efate
'
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 affil
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)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act
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 then:
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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
A,
SECTION 5 'DESCRIRTION°OF°PROPOSED""VYORIK' h ck:all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other ]
Brief Description of Proposed Work: 1S , S�-'(,? ,� s,rtl C
Alteration of existing bedroom Yes lr'` No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes L�'`f No
Plans Attached Roll ❑- Sheet❑
fa:"If=New.ho'u'se':arid or addition to ekisting""hou"sing, complete"the fo(1owin
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 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-7r— as Owner of the subject prope
ereby a thorize to ac
my be all, in all mat it&o n by�th:isb�uuilding permit ap lica ion.
6 25
Si nature f Owner D e
r
I, ✓� 5 as Owner/Authorized Agent
hereby d at the state ents all information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and pena ties of perjury.
r
Print N r
Sian at re,of ner/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
Frontage
Setbacks Front
Side L: R: L: R:
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 y 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:
r� r� i'. City of Northampton Sat is f
�l
Building Department Curbctt/ t: a er..i m
I 212 Main Street
7 5ewier%Sepc£., ta;i�; b '
I{ JUN - 2002
Room 100
ortha WaerfWi1 Avatfab tt `' _ �
mpton, MA 01060 Two Sets of S�fr c raans `
C
,Hne 4 3-587-1240 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:
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:
0 - �� ,fix
Name P int Current Mailing�Add
re� :
aE — -------- --—
Telephone
gnature
2.2 Aut rized A t:
Narrte(Pri „�, Current Mailing Address.
Signat Telephone
SECTION 3 - 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 (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) _
5. Fire Protection 2-s����l
6. Total =(1 + 2 + 3 + 4 + 5)- Check Number
This Section For Official Use Only
Building Permit Number: � ? Date.Issued:
Signature:
Building CommissionerAnspector of Buildings Date
File#BP-2002-1079
APPLICANT/CONTACT PERSON C&T Construction
ADDRESS/PHONE 15 Fairway Drive (413) 586-4965
PROPERTY LOCATION 38 LADYSLIPPER LANE
MAP 35 PARCEL 222 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Tvpeof Construction: INSTALL 2ND FLR LAUNDRY(OPEN WALLS FOR P&E)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 062884
3 sets of Plans/Plot Plan
THE FOI,,LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO MATION 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 Commi
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.
z BP-2002.1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1079
Project# JS-2002-1742
Est.Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C & T Construction 062884
Lot Size(sq. £t.): 43516.44 Owner: CAHILLANE DEBORAH J
Zoning: SR Applicant: C & T Construction
AT. 38 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON.6111102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2ND FLR LAUNDRY ( OPEN WALLS
FOR P & E)
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 6/11/02 0:00:00 2981 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo