36-194 (5) AUK-06-2002 03 : 15 PM DONALD Y STILES 4135865121 P. 01
F Crii�
of �,TortIj mptoil
p _ E R2a�.,rhncrlle - —
�- DEPARTMENT OP 13011-DrNG tNSHC-TI S — —,
212 Maven street ' Municipal D,J�Ymp
Northomptorl, Mass. 01060
v,,() Zja,wS COt UENSATION [NSM-ZA-rCc: % I IDAVIT
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�,�itls � S�Itncrp�tJ pl;eec of busirlr_ss/residenr;c� t:
_._�------ (sn-cWcity/sta f'vp) —
do hereby ce idy, under the pa_iru sad penalties of pr-gury,
( ) I am an employcr providing the following wujkWs cornncn�_,:ion cove.-24c fot inY
err)J)1ovr_(:s ,tia �ans� un tins)ob
(1�sur�r Concz-vv) (Pet;c:N. r) Dasc)
I aIM z so!c ptoulictof, gct)eral coneraetor c, c..c) and have hued
the ccnt ra Tors liste4 below cgho have the following wUr e s moon pe6cies:
Ne^o OULt n. - Wc->- 34! S-_339fIr7-ors_
( :aroc ai Co:r.ncto:s (11)--u lice Colnoan)•r?cue-, Nusw--', (t:-.r+;o:.on Datc)
-- GT 2!11c of Coutractor) --- (lnsaranc; ComoauvfPoticv ",Uotr[) (Laois;Lion Daic)
(Name of Coasractu) Onluran c Companyrry cy 14;imt--r; - (t= pirueo Date)
(1"i u c c,`Corrrzctor) (htran Cow;zu7lf'ofscr [�umb� : ii uauan Dais)-
p;ohr,,etor and have no ooc work-ug for me
( ) ? am a Iwme owncr perfortuino all the work mysc:-If
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.cur ur..6- w s 1 JOo.W.rritx >cII or ur w an.ycy cr4 6,A)pensti 4 c,c r"',of.Stioc--k 0-1-wd.
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DEPARTMENT OF BUILDING INSPECTIONS '
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(li censce/perini tt ee)
with a principal place of business/residence at:
(phone#)
(8t=Ucity/=&2:ip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration 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 Compauy/Policy Numbcr) (Expiration Date)
r.
(Name of Contractor) (Insurance Compaay[Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atilt+additiomi shcct ifnexessary to include iaformaiioa pertaining to all ooatr d rs)
( ) 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 avzwc that while homcownera who emplay pcmom to do mainttaaacz,oausb-=oa or rcpau work en a dwelling of
not more than thrco units in which the homvowncr r=dcs or on the grounds appurtenant thezcto arc not gcrxr111y ooaiidmd to be
employ=undcr the wmicces cea�on Act(GL152,ss 1(5)),application by a homco%-=for a 13-31,oc Permit may evidence the
legal statsu of an amployec under the Worfra's C.ompemaiion Act_
I understand that a oopy of this ctntcmcni may bo forwarded to tho Dqm mnit of Indautrid Aocid,=&Offioo Of Imrusnoe for the
coverage wrificatioc aad that failure to tw=ooverago under section 25A of MOIL 152 can lead to the imposition of a imiml Pcn&W-
oonibtiag of a fine of up to S1,500.00 and/or imprisoamart of up to one year and civta pcasltia in tfic form of a Stop Work Ord--and a
firm of S 100.00 a day tig&inst mc.
For dcpn txm use only
Permit Number
7�z 31, � �p
Iot
Stgate of LiccnscxPernutte e #
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIQN 10 YVORKERS':COMPENSATIOWIN URANCE AFFIDAVIT(MG.L. c. 152, §25C(6))
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 the 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
t
R PO"r bh D: O
'x ..$ F*'.44:>Sa�+Y;.,.. ,r Yk:-'s"esF?i�'7i��m�,y,v„r�."rk R& •u:'s.�l�v..�;.. a h�'�5, :� «,RG' .'.�3�?."z.a ,i;;7?.:f� ...SVYi..,,'fi7Uip;, ;'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ]
Brief Description of Proposed Work: �� ! K �Y' '2
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement es No
Plans Attached Roll❑- Sheet
e i*t" to ezcs#in us' a
10
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 construc io Dimensions
V
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 7a `OWNER AUTHORIZATION TO;BE COMPLETED WHEN
OWNERS AGENT,OR=CQNTRACTOR APPLIES FOR BUILDING;PER11l�T.
I, �( as Owner of the subject property
hereby authorize to act on
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.
z U
Print Name
�. 7/L�Z
Signature of Owner/Agent Date
f
Section 4.
ALL INFORMATION MIDST 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 Z-' �J
Frontage � /C� /
Setbacks Front
Side L: R: L:2-1-�R: 3 G c;
Rear �10
Building Height 3s-
Bldg.Bldg. Square Footage � % '—L/
/ J
Open Space Footage %
(Lot area minus bldg&paved 2�
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO lC 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 �C
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 aqj litlons of signs intended for the property ?YES
No
IF YES, describe size, type and location:
Q C Northampton
Ani! i epartment
, Main Street
JUL 2 3 2G02 oom 100
No-tharipton, MA 01060
BIJIL -587 1240 Fax 413-587-1272
DEPT OT ,
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEdTIONJ-SITE fN,FORMA '11
_
1.1 Property Address:
W
Zo .
flo
EIm St zDistrict CB ..
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED°AGENT
2.1 Owner of Record:
zr�I�.� '► .(-��lc., - �G�v �a(a!� i�.i f 7�;r (� ., as f +Name(Print)(Print) ! ✓rt-t� �j� �— S Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3 -iESTIMATED GONSTRUCnON:COSTS
Item Estimated Cost(Dollars) to be Official Use'Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical �� A- (b) Estimated Total Cost of
Construction from 6
3. Plumbing All 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 Permit Number: 0 "' Date Issued
Signature:
Building'Commissloner/Inspector of:Buildings Date•; ",
File#BP-2003-0073
APPLICANT/CONTACT PERSON STILES ELLEN T
ADDRESS/PHONE 788 BURTS PIT RD (413)586-5121 Q
PROPERTY LOCATION 788 BURTS PIT RD
MAP 36 PARCEL 194 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 10 X 15 DECK FOR FUTURE SUNROOM
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 ' n
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.
r
;� .. . BP-2003-0073
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0073
Project# JS-2003-0161
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 70567.20 Owner: STILES ELLEN T
Zoning: SR Applicant: STILES ELLEN T
AT: 788 BURTS PIT RD
Applicant Address: Phone: Insurance:
788 BURTS PIT RD (413) 586-5121 O
NORTHAMPTONMA01060 ISSUED ON:811102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 10 X 15 DECK FOR FUTURE
SUNROOM
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 Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/25/02 0:00:00 1052 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
788 BURTS PIT RD BP-2003-0073
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 194 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003.0073
Project# JS-2003-0161
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 70567.20 Owner: STILES ELLEN T
Zoning SR Applicant: STILES ELLEN T
AT. 788 BURTS PIT RD
Applicant Address: Phone: Insurance:
788 BURTS PIT RD (413) 586-51210
NORTHAM.PTONMA01060 ISSUED ON:811102 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 10 X 15 DECK FOR FUTURE
SUNROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: -7
Footings: i55 0 K
Rough: Rough: House# Foundation:Dlf d�J
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Finale/< Z:�7'O2
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:��
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/25/02 0:00:00 1052 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo