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35-294 (2) xl- C) iJ lr 10 C I'v a�ttMfP2.O - - g =' , � f3�r<saxrhnrtcts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Bui1dirnr Northampton, Mass. 01060 WORI{1 R'S COMPENSATION MURANCE AFFIDAVIT 1, _X14��__ _1!Lt,a n T�_�_-►�� ------------_ _ _ ___ (Ii�nscrJperrni flee j with a principal place of businessJresidencc at: ✓LD � 1 L�11� 3 do hereby certify under the pains and mialties of pul ury, than. ( ) I aril an employer providing the follo%vint_ "vorr_el's my employees working on 1111s job-. (Insuanr Comin}') (Policy Number) ( pintion Date) O I am a sole proprietor, general con'Tactor of homeowner (circle one) and have hired the contractors listed below who have the followi .r workers cn:n�.?ensstion policies: (Naine of Contractor) (Insur-anc-c Coinpany/Pohc-y Number) (E",,ration Date) (N:)-ne of Contractor) (Insurance Company/Pohc)'NwYb--r) (F`vi� non Date) -- Q"Tame of Cont actor) --- - (Inszlranc Nlimt-;�,I) - (E1,; lion Date) (Name of Contractor) (Insurance Comth ny/Pohcy Num r) (Hxi�7-::tion Date) (atiadt a,M ti cc I c cf if r.ccczur:to inickki,mfxinatioo pcYa inE t:;ell ( � I tuna .�olc proprietor and have no one ,vorking for me. O I am a home owner performing all the work nlYsclf. NO hI::plese be aura c ttul�i{ lr n A�nxrs who eIPloy;>zc u not r occ th n thrco unill in he 1>rxoavcr rciiva cr of L',-Erua.�1_3 z w crW 14 ac o e.-c txt Ica rally ax�!iL�-rcd to b, calployvs unc;cr the tvod:tis catxcsttion Act(GL152rs 1(5)),ng-iioa6on by a homnowrcr for t I;cc c cK P�^:i:r_y�ei -sxc tlx legal cta[ue of an employer under trap Wor?tcez Gon4>oo ation .d- I uzi3c ti d thit a copy of this ctatcn>aii msy bo fomTac cd to tho Dcpn t,, nit of Indium d ArciL- &Oftioo of La:runx for tlm covczagc verification ctnd that f:ilurc to:mtrc covcrnga under:cCioo 25A of),(M,152 can Ictd to the imposition of r--i-d Penalties coasutiag of a f of p to S I-500.00 atlN-irn isocmea t o£up to cne)^e r r,:,j ei,,l penalties in tl.c fo m of a St,-,)w` Ord-and a fittc o Qp y iFrtiin;l fir_ Foe dq%a:t:zrtnl uie only Permit Nlttntx 1` I"ot si to Ltc n_cJPcrnuttcr. SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : JAb r-- f I��YVT 1 A4 n License Number 0 7/ Z Z \o Address Expiration Date Signature Telephone 3 3 -3 t - -Ci 9:'Re i ere Nome`Im v rr7er Contractor „ ;. Not Applicable ❑ Compan_Name Registration Number /4IfGi+KT—W dU D U/l A!h/ (T J2f .s76l!t I n1 132 9?L/ - --- ---- Address Expiration Date (0 0-k T_ 12(7)4 f ��Telephoneq 13 '33 /2 S Z U - oS_ 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 affid . t will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... G7� )Ern 19 L d P11: f me Owner-E',empti°on The current exemption for"homeowners"was extended include Owner-occupied Dwellings of one(1) or two(2) families and to allow such homeowner to engage an individua or hire who does not possess a license, provided that the owner acts as supervisor. CMR 7%, Sixth Edition Sectio 108.3.5.1. Definition of Homeowner erson(s)who own parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one riyo family dw ling, attached or detached structures accessory to such use anal/or farm structures. A person who constr is more t an one horne in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to th uil in- Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work erforme under the buildiriL, permit. As acting Construction Supervisor your pre ce on the job site will be required from time to time, during and upon completion of the work for which this pe nit is issue . 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) 01-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 compliance with the State Building Code, City of Northampton Ordinances, State and Local "Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature —_ __ '4 Z X 3 6? F(- O /2 PL t.JVo � C. FCa-t> K �Z D K (F w)4-t LJ �i A201 TX-t-- Al p, /v Af /IV 6- 3%2 64-r773: in!�t s ! an �s?q—Z L s /�L E T/L SECTION 5-,DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s),�t- Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work:�_n I/ywl st.Em1tIV T /b _- 9L"" 14-6-QV" Alteration of existing bedroom Yes No Adding new bedroom _ Yes _ No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet L.j 6a. if NeW hduse.and or„'addition to existing.housin completethe followin> : a. Use of buildin : One Family Two Family Other b. Number of rooms in ch family unit: Number of Bathrooms c. Is there a garage attached? — d. Proposed Square footage of new co traction. Dimensions e. Number of stories? f. Method of heating?_ Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance _— scheck Energy Compliance form attached? __- h. Type of construction i. Is construction within 100 ft. of wetlands? Yes _ No. Is co truction within 100 yr. fioodplain Yes__ Nc, 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 Prvate well City water Supply_ SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN _F OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize � – _—____— ------ ------ to act on my behalf, all matters relve to work authorized by this ouild �-._? perr-nit application. Sign ture of Owner __ Date VX 09_7>fVtA h — as Ow!</AuL o�Agent hereby declare that the statements and information on the foregoing application are true and accurate, to knowledge and belief. Signe under the pains and penalties of perjury. rT Print Name J Signature of Own t Date t 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 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:_ City of Northampton SatusofPerrxtt# Building Department Curb Gut/D `ve a e.• "' ;�,�k� 212 Main Street S6,wer/'S'P Ic Room 100 WatWw"@ix"Val Northampton, MA 01060 Two Set ofStY phone 413-587-1240 Fax 413.587 1272 P,Iot/Site Pian Other Speci Ij�P � t , ` ------ ------ -- --- — — APPLICATION 70 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be-completed by office 1.1 Property Address: �3 w0 0D Of^4 .Dru v� Map Lot Unit Zone— Overlay District Elrn St. District__ C13 District ____- SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2_1.Owne_r of Record: A-anL6 c - K1-i�c E_Ly-%/CI+ -- ------ — - - - - ar n IS ddress. `igr�,a-ire 2.2 Authorized_Agent_ 114.D C,. m o n-T A4 k-r, �igrat.,r T�:i ,ne SECTION 3 _ESTIMATED CONSTRUCTION COSTS ,�;r;� Estir anted Comet("��I'as` Official Use Only '. cornr)leted 1;Iding Permit t=ee 000 ed Total Cost of 31 Building uction from (5�i ;it�i r, t P ermit Fee 5. Fire Prot- t!on I I 6. total = (i + 2 + 3 + 4 t 1 Z 0c) < hecn NumlDer This Section For Official Use Only w� ---- — ---- Building Permit Number- v7—_�<�3—_—__—.___ Cate issued: I Signature: — Building Co'rnmissioner/inspector of E3uilc rs mate File#BP-2004-0503 APPLICANT/CONTACT PERSON JADE MORTIMER ADDRESS/PHONE 28 FORGET RD (413)339-4298 PROPERTY LOCATION 93 WOODLAND DR MAP 35 PARCEL 294 001 ZONE SR 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: FINISH BASEMENT INTO PLAYROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 071226 3 sets of Plans/Plot Plan THE FgELOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF,QRMATION 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 C ssion a i 1200— Signature of Building O icial 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. 93 WOODLAND DR1 BP-2004-0503 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-294 CITY OF NORTHAMPTON Lot: -001 Permit: Buildina Category BUILDING PERMIT Permit# BP-2004-0503 Project# 35-2004-0714 Est. Cost: $6200.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grout: JADE MORTIMER 071226 Lot Size(sq. ft.): 32713.56 Owner: CIRINCIONE KIRSTEN&JANE LYNCH Zoning: SR Applicant: JADE MORTIMER AT: 93 WOODLAND DR Applicant Address: Phone: Insurance: 28 FORGET RD (413) 339-4298 HAWLEYMA132974 ISSUED ON:10129103 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT INTO PLAYROOM 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: FeeType• Receipt No: Date Paid: Check No: Amount: Building 10/29/03 0:00:00 500 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo