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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WOIU: E 'S COMPENSATION INSURANCE ArFIEDAVIT
(li ccnsedpermi ttcc)
with a principal place of bus iness/residence at: _
(sa=t/ci ty/staic/a p)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following worker's cornpensaLion coverage for Inv
employees working on this job.
(Insw-nom Cor�r�v) – (Polio: Numb--r)
XI am a sole proprietor, general contractor r homeowner cie one) 2nd have hired
the contractors listed below who have the follo�� g worker's compensation pohcies:
(Name of Co.. cwr) (Insurance Company/Policy Nuulbcr) (1=>:;>>rauon Datc)
(Name of Contractor) -- (Insurance Comoau".1polkv NI UMn rr) (-Exp fation Date)
(Name of Conn-actor) Qnsvrancc Compamy[Polic�- NLunbei) (Expim600 Date)
(Name of Contractor) (Insurance Coinpany/Policy Number) (E\piratioa Date)
(edacb additio¢alrficC if ncc,czsi.n w inc!ud:inforsaaaoo pertaining well o«ri-ar..on)
( ) I am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:ptc=4c be aware chit vlr lc bomcorn+vcn who coaplay peso=to do m Z1manocc a asnxt oo er rcpau Boric oo a d.�Aling of
not moos:than thtoo units in which the 6omoowncr revdc,oc oc the Grounds zppittcaem tbccto ere oot ecoa-atly oo=dcrcd to be
cmployrrs under the woe.cr'% ioq Act(GL152—s 1(5)�zwLca-don by a bomoov�mcr for t Been c oc permit may cvidmoc the
legal ctssuc of an employee under dw Woci cue C.00zpomaL on AeL
I undcrst►ad that i copy of tbii rzstca ml o y bo forvrar to tba Dcpartmmt of loduY.rial Aoodma'Offioo of lirtir=oou for tba
covcraSc vrnf c:600 and that f_ilurr w aco=coverage coder soctioa 25A of N(OL 152 can Irsd to rho imposdioo of crimiatl pcaaltics
oomistiug of a Gne of up W S 1 500.00 and/or tmpriioomcol of up to ooc year tad attil pcnzhio in the form of a Stop Work Order and a
fim of 5100.00 t day tgaiwa tnc
For Y•.. um —y only
Num —_
Permit ber
Li
Map I::_ of _— —
Signathirc of Li 6 ua e
ECTIQN $-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
"3 `!#o . Itti ,` tr ; i `• ix°r cr,'., . .' Not Applicable ❑
..,�
Company Name Registration Number
Address Expiration Date
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 affidavit
will result in the denial of the issuance of the building permit.
igned Affidavit Attached Yes....... ❑ No...... ❑
1 .. dale wnea Eeripon
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
Nort ampton Ordinances, State d local Zoning Laws and State of Massac usetts General Laws Annotated.
Homeowner Signature
CT ON 5- DES C—RIPTION OF PROP WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows � Alteration(s) O Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs Decks Siding [ OtherX'
Brief Description of Proposed Work: C2K'—Z X S�� d6eih!�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 11 - Sheet❑
6a. If NeWwh' 's`e and;,,6r!additJ._pw,WexJst in-9 hou!;ing, CompleN the following:
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
0*4 Energy Conservation Compliance. Mascheck Energy Compliance form attached?
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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
?h'e—reeeclare that the statemen and information on the foregoing application are true and accurate, to the best of my
-7 knowledge and belief.
igned and pains pd penaltie's_ rjury.
nt ��20/ ,� ���s � ��-/�_dam----
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
�
Building Department
Size as riv d p' Q) U `� U' " "
Frontage
e�.� '7 s
Setbacks Front
Side L: R: L: R:
90 '
Rear UA f-I/
Building Height �� ?
Bldg. Square Footage % 3Q
Open Space Footage % i
(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:
o a
dh-i 1 orthampton St to f e t
�� ��ullgi1h Department
k 5 2 ain Street rye � a �� �
,U, � MAY -
�" .�...-- �o m 100
Im n, MA 01060 Cw St 1 } r
E .1240 Fax 413-587-1272 l l
C?ther Slae�t
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 I_�rt�T Ulnit
Zone Overlay District
Elm St.District CB.District
SECTION 2- PROPERTY_OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��L M -le�'//
Name/(Print) j Current Mailing Address:
✓ �---- Telephone
Signatur
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION,COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by perrnit 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
Total =(1 + 2 + 3 +4 + 5) Check Number
Av
This Section For Official Use Only''
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2000-1017
APPLICANT/CONTACT PERSON JACKSON CAROLE ANN&DEBORAH M
ADDRESS/PHONE 90 WOODMONT RD (413)586-5361 Q
PROPERTY LOCATION 90 WOODMONT RD
MAP 25C PARCEL 014 ZONE URB
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: S L ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
TH OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Co on Permit from CB Architecture Committee
/ Od0
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.
90 WOODMONT RD BP-2000-1017
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-014 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Above ground pool BUILDING PERMIT
Permit# BP-2000-1017
Project# JS-2000-1845
Est. Cost: $3363.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 28793.16 Owner: JACKSON CAROLE ANN&DEBORAH M
Zoning.URB Applicant: JACKSON CAROLE ANN & DEBORAH M
AT: 90 WOODMONT RD
Applicant Address: Phone: Insurance:
90 WOODMONT RD (413) 586-5361 (�
NORTHAMPTONMA01060 ISSUED ON.5118100 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ABOVE GROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 5/18/00 0:00:00 1137 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo