36-185 (3) /fvLS yet
X Sr JbCrL 13 L&
4t,l PF_.it 1 lam! 0 ►K K S
Sc� At Tv +3 ►`t
S►e�ss � KS z v�
S OFF G rt t
u,x 7 .,/
J►�tixc �t, '�K w� �/s Cf� x id►tE S)niPSo„v (C)vC116.74 10s ST'
B
y� `f K`I
S
k
1
(, srrPs
/ 2
Inc C K.1
CUtli T�hi L' 4`LS
i
3 f-iii W%
-I-�,s►�
d
V
a Y XLl ,D7+>C
2XL 41-cSr)4K$
PL v S
L &DG )4.lC +
',I'C-7 S r5'
� c/ Xb 0.44 ro cs, r ,4.
M
STS?S
APR
i A, R
�20��
0 4.�liAHpT� �
-
$ 6tsaxrhasrtta
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORICEIR'S COMPENSATION INSURANCE + + AVrr
I,
(licenseelpeTmittec}
with a principal place of business/residence at:
(phone#)
(streeUcity/statelap)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (F Timtfbn 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:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Exp radon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Hxpiradon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiation Date)
(attach additional she if no=m xy to iacWc inforuubon pcatnining to ell oca4acton)
XI 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 that while homcow ncm who employ p=c,=to do mein�comtru oa of rWau work oo a dwetl of
not more than thrco units in which the hon»owocr resides or oa the grounds appiutmant thercto arc cot grncrally eemWard to be
employcr9 tlnser the works t;n oa Act(GL152_"1(5)�application by n homeow=for a liccose or puulit may cvidcaoc the
legal riatue of an employ*<under tho Worir.oea C.ompoma2io Act.
I un&re_nd this a copy of thv ctatcmcat may be fbrwn dad to tho Dcpartn,od of Ilia!A.cadmh'Office of Inau+noo for the
oovemge YcrMeatioo and that failure to aeatre oovecago under sbcdon 25A of MOL 152 can lead to tha imposition of criminal pens cs
comieing of a ftne'of up to S 1,300.00 and/or imprisoameut of tip to one year and civil pauhcs in the form of a stop Work Order and a
fine cf 5100.00 a day tgaiwl mr-
------------ -- For dcp-�—only
permit Number
hbo
Lot#
Si of Liccnsee/permu e
N& � ''
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i�- L' VYL—C)YL. I /—1 4x-
License Number
2(o �yL(,mot; ;e o r4 6 7 t 2 Z Go
Address Expiration Date
Signat Telephone '/ a
n n" r�MMWMUKM MMEM Not Applicable ❑
f�I�J�YK i tn)o a� Oyu i�,���v �r ��ST 6 K�i7 � ►.�
Co mpany Name Registration Number
a V C
' c J2of1 �� / 3Z 57V
Address Expiration Date
L Vc (7 13 3°j Telephone ,337-L/2 Y
SECTION;10 W00RKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25'C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of the building permit. /vo K-- M lot-C) S
Signed Affidavit Attached Yes....... ❑ No...... ❑
RON
Xm �
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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
j ;
,
3i3;^,.i 6 S A {?'ih' p tQJN4 x'.h,. ,�,�„¢,�d 3 � n' 5� 3d � ,kiz
SECTION 5 DESCRIPTION O 70ROPOSED!VI ORK(check ail applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [✓< Siding[ ] Other [ ]
Brief Description of Proposed Work: 3 Z2- d CIC
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes '� No
Attached Narrative❑ Renovating unfinished basement Yes ✓ No
Plans Attached Roll ❑- Sheet❑
6aIfi�New�hoise�ando"r"�aticlit��n�to Ilst=in ho`�iis`�ing;comple' "e""~tli`e`#�'1'Ioin�:
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 l
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
OVNNERS AGE_T OR CONTRACTOR A',pPL1S FORUI,LDING 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
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
C(
Signature bwne Agen Date
1
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 313 �3
Frontage
Setbacks Front Co tD 1
CP
Side L: i R: Z 0 L: C( R: 2 0
C O
Rear o
Building Height
Bldg. Square Footage J q�� % r rys
l / —�
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 v 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/here any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
of Northampton
---� u ling Department "
r .. �a
2 Main Street Se ef.
ASR _ , 20'02
!1 Room 100
Na rWefl , V
Nprtha pton, MA 01060 its o' S r a
41;3-58 -1240 Fax 413-587.1272 Plotl"' e a
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION;1 SITE INF.ORMATLON.
_ This sec o o e c�0 ed'
1.1 Property Address:
9 "'3 UK7-s r r t2d,�
Map
Zone
Elm St:District' 3 CBUs rlct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
to✓c� a q Ek-Ll rx ON 3 N I artr �9 fr gux -s ?191 T r2-6►i D
Name Prin ) / Current Mailing Address:
Telephone _
Signature rO
2.2 Authorized Agent:
Nam t Current Mailing Address:
33c7 -- L/2- -I
Signatur Telephone _-
SECTION 3 - ESTIMATE ':,CONSTRUCTION COSTS' _
Item Estimated Cost(Dollars) to be Official Use Only
com leted
by ermit applicant
1. Building ! u o o (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 =(1 + 2 + 3 + 4 + 5) / v , o e ° Check Number
This Section For Official Use Only
Building Permit-Number: Date Issued:
Signature
Building Commiss'iplier7Inspector of.Baildi gs_.; D ..,,
File#BP-2002-0834
APPLICANT/CONTACT PERSON JADE MORTIMER
ADDRESS/PHONE 28 FORGET RD (413)339-4298
PROPERTY LOCATION 898 BURTS PIT RD
MAP 36 PARCEL 185 001 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: CONSTRUCT 322 SO FT DECK
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9XMATION 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 Co ssion
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.
898 BURTS PIT RD BP-2002-0834
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 185 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: Deck Addition BUILDING PERMIT
Permit# BP-2002.0834
Project# JS-2002.1393
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JADE MORTIMER 071226
Lot Size(sg. ft.): 31232.52 Owner: REYMOND WENDELIN K&
Zoning: SR Applicant: JADE M 0 RT I M E R
AT: 898 BURTS PIT RD
Applicant Address: Phone: Insurance:
28 FORGET RD (413) 339-4298
HAWLEYMA132974 ISSUED ON:418102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 322 SQ FT DECK
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 4/8/02 0:00:00 248 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
.. _
- 'q � f w'"
1..'.
898 BURTS PTT RD BP-2002-0834
GIS#: CO Y, NWEALTH OF MASSACHUSETTS
Map:Block:36- 185 CITY OF NORTHAMPTON
Lot:-001
Permit: BuiIdine
Cate o Deck Addition BUILDING PERMIT
Permit# BE 002-0834
Proicct# JS-2002-1393
Est.Cost:$10000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JADE MORTI MER 071226
Lot size(sa ft) 31232.52 Owner: REYMOND WENDELIN K&
Zoning:sR jgnlicant. JADE, MORTIMER
- AT- 89€-BURTS PIT RD _
Applicant Address: Phone: Insurance:
28 FORGET RD (413) 339-4298 ,0 F 1�"
HAWLEYMA132974 ISSUED ON.4/8/02 0:00.00 "� '� J
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 322 SQ ET DECK t`
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: t O L c3 lt�
Driveway Final: "^`l r-6 g
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oils Insulation:
Final: Smoke: Final: Ott
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu n si nature:
Fee Type: "Reeeipt No: Date Paid: Check No: Amount:
Building 4/8/02 0:00:00 248 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo