36-027 0�-111AM
F= � tig (rZf�l �xf �az:#(j2�111jl�Dlt --
� B �KSaachnsclta
d DEPARTMENT OF BUILD0\TG INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORKER'S CONTENSATTON INSURANCE A=, AVTT
(liPej��)
with a principal place of business/residence at`.
(su-�t/ci ty/staLcia P)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following work=er's compensation coverage for 1ny
employees working on thus job:
(Insurance Compan}) (Policy Number) (Expiration 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 ConLr actor) (Ins-u nc–t Company/PoL cy Number) (Expiration Date)
(Name of Contractor) (Insurancc Commnv/Pok—,, Number) (Expiration Date)
(Name of Contractor) (Insuranc; Compan y/Policy Numbu) (Expiration Date)
(Name of Contractor) Rusuraacc Compafry/PoLicy Number) (E)piration Date)
(aaach additioml sheet ifneoc=xry to ix u information pertniaiag Wall ooatracto s)
f 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 awlrt:the whilo homoowncrs who employ persons to do n ,.r„,= coast%=oo or rgxiu work ou K dwelling of
not morn than throe unfu in which the bomeowucr resides or on the grounds appurtenant tbacto ate oot generally 000sidacd to be
—ploy-cm under tha woz+cr's oompc soon Act(GL 152 a 1(5)),application by a homcowarr for a riecnsa or permit may evidcnoe the
legil rtants of an employee under tho Workees Compomation AcL
I understand that a copy of this ru anent may be forwarded W the Department of Indzrt d Aoadmi>'OfSoo of lm+usooe for the
oovaagc vcrWc:tioa aid that f_ihmc to t omm covcmV under seuioa 25A of MOL 152 c2n Iced to tha imposition of aimiasl pcnalvcs
000sistiag of a fine of up to S1,500.00 and« of up W one year and civil pcnattia is the form of a Stop Work Ord-and a
fine of S 100.00 a day agniast me,
For depastmtrxW use only
Permit Number
��— � /z� e MaP4 I.ot R
Signature of LiccnscclPctmtttee e
SECTION 8-CONSTROPTIQN 5ERVICrS
8.1 Licensed Construction Supervisor: ® Not Applicable ❑
Name of License Holder: ��s ✓G9 c �E ✓ e6� 19 4
License Number
Address Expiration Date
Signature Telephone
o'
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,§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 tlsie 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
check all-a ticbl5 DSCRC 10 :OF:P OPOSE e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks—.n Siding( ] Other [ ]
Brief Description of Proposed Work:+Vis/- / C°`-vix c.l6i -.;?e, Llk-
Alteration of existing bedroom Yes '�< No Adding new bedroom Yes -e No
Attached Narrative❑ Renovating unfinished basement Yes 3<- No
Plans Attached Roll ❑ • Sheet❑
5f ifi Wo ':
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 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 OWNEIAUTHORIZATIIQN T4 BE CQMPLETED.WHEN - s
QWN� S„AG NT O C U PP IES to B tll< I,I G p RM1T ,
as Owner of the subject property
0
hereby authorize ✓ - _ A n to act on
my behalf, in all matters relative to work authorized by this building permit application.
Sig Owner # Date
/r. ,� ✓� �j,�) as r/Authorized Agent
hereby declare that t e sta ements 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.
7;�&O�Mefz ;;2
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
C Building Department
Lot Size r�3i d)q
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage 107 %
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 X 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 #
'L'
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:
5fi
Z- ct,
o
av
IQJ
>(
or"
rL-
l
L AUG - 1 2008 ,F
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01062
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
This s �ctontnbiotintetedf �affe3
1.1 Property Address: key
� I
ISGtSs `e
SECTION 2'- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Njaili n Address:
Telephone
Signature
2.2 Authorized Agent:/
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3IS71NfATEb:COt �TRUCTION COSTS
, .
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
0 . eel)
2. Electrical (b)Estlrrl ted Total C� of :t f ,'
bra- a Construction fr0'r ,fi�
3. Plumbing Builid ngPermitflbe
4. Mechanical (HVAC) ,
5. Fire Protection
6. Total =(1 +2 +3 +4+ 5) Check Number
this Section I or Official,Use.On
Building°PermitNumber pate Issued
Signature
B.u�ltirtg CgCltrnisstonerJ,I or ofBu ngs, - x Daie d e
t
Ak
BP-2009-0134
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2009-0134
Proiect# JS-2008-000742
Est. Cost: $1650.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO
Lot Size(sq. ft.): 13198.68 Owner: ADAMETZ WOLFGANG
Zoning: URA Applicant: RICHARD DENNO
AT. 36 DEERFIELD DR
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584-0852
FLORENCEMA01062 ISSUED ON:81512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SLIDING DOOR A J ra D EGK
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: Date Paid: Amount:
Building 8/5/2008 0:00:00 $50.00514
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
A
zixv
AWF.
Swx.,'y.n
3 , I i+ti.FzxFx
t '�`
�k` `�Ik 7;
'! 4 .R d', " fr
Fad
k
a
� � t
{
r
A+ M,�
cow
td
oil
lox,
MR MA
TO
4" 1�
s.k g_,,
cl g Mr, -,+ ' ,.•5 a Ogg
c
`� `': R q. O gg
'1. ""
>" � +'
e> I
114 SHIA?loons"
tm'
64 -y' ..k �,3.p 'yF a t. 34° #hae x �``�" 4 y, s d t a' ,a f t ;;. c. �`" ,'..
SINT�� _ r a
I -M, i
AS
�AVXMVASMI psi
r 'a "r.3'y�S
i^ ' C' ,z• � ✓ ti i, F' �" '`" x # ;��x xE" Ada. "�"' �*.. iF ��'�' ..
,+`
XA
;x rd, z
a# ,
'd`
3
!iv"APRq1
w, ` r
+'"'` -t�� ro�"r- � �e' `� .?.�a� �: � 'a^� ;T,;rsa _ '�," '-r*'Ayd`k�,�" au*,r.�.� " , •� `� "�F?.Z "?,bra�� {'fix r_ : '�i .s.,,..:
4 .a m
".-s � v-.: x s'f^`ri ,�y H �"' - �; ..+"a.t= ,a`:�' s*=a i - ' ,K• ,,..e�
v "01 ra-'�''"1 Sra
k^ r yt y s •W'.`g
MAO
lot
fill lot..
i
_ r
,
VIVAa
36 DEERFIELD DR BP-2009-0134
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-027 CITY"OF NORTHAMPTON
Lot '001 - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: B DO NOT HAVE ACCESS TO THE GUARANTY"FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2009-0134
Project# JS-2008-000742
Est. Cost:$1650.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RICHARD 0ENNO
_Lot Sizesscl.f?.;: 131 9f�.88 Owner: ADAMETZ WOI,PGANG
Zoning: A
AT. 36 DEERFIELD DR
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584-0852
FLORENCEMA01062 ISSUED ON:81512008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SLIDING DOOR, /a X le PZ-c
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: .. 'Meter:
r
Footings. d
Rough: Rough: $ House# ' Foundation: !t -Q°
Driveway:Final: �.
Final: Final: �,qbj?
�V Rough Frame:
Gas: Fire Department Fireplace/Chimney:
tougn
- -'�- Insulation:
Finah.. --- - -
Smoke: -If
Final: t!hC� �a�
THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc ft nature:
FeeTvpe: Date Paid: Amount:
Building 8/5/2008 0:00:00 $50.00514
^_12 Main Street,Phone(4!3)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo