28-001 t
04�ttA1 f PTO
9 B �asaachnsctts'
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DEPARTMENT OF BUIL I-NG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSA'T'ION INSURANCE AFF'MAAVTT
(Il cen_serJpemli flee}
with a principal place of busmess/residence at:
24 Z ! I�� - Rd, f—kff�_ 141 r�P(phones#} y!3-5 -� 77c!
(str�Ucity/statrhz p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worke,Js compensaLon 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) (Insuranoc Company../Policy Number) (Expiration Date)
.,
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (lnsumnce Company/Policy Number) (Hxpimtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional Lfnaccuary to include iafocmiiion paiaiaing to all coafrnc ion)
O I am a sole proprietor and have no one working for me.
(V� I am a home owner performing all the work myself.
NOTE:please be awam that while homcow^ncra who wxploy paiom to(So mainicaanc�oxastrL=oa c:rrpair work on a dwelling of
not mc"than throo units is which the hone owncr residc3 or oa the grounris zppurtcnant thacto arc not generally ooasidaed to be
cmploycm under the worker's ccxi�on Act(GL152,=1(5)),applicztion by e homcowncr for a ticcasc cc permit may evidence the
legal rtatus of an omployec under tho Work,e's Compensation Ad
-
I understand thst a copy of this statement may ba forwruded to the Department of Iodrizfrid Acczdcn&Office of In-ru sr+co for the
coverage vaification and that failure to scatre coverago urds soc6oa 25A of MGL 152 can lead to tho imposition of mmi w penalties
oonsiitiag of a fine up to 11,500.00 and/or imprisoumcat of up to one)tar and civil panitics in the form of a Stop Wort Order and a
film 01 5100.00 a day against me.
Foe dcputrrr�'1 uk oaly
\`1 Permit Number
�
:�,� S gnahue of Liccnsee/Pe e
SECTION 8--CONSTRUCTION SERVICES'
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
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. _
Signed Affidavit Attached Yes....... ❑ No...... ❑
fil. om O rie �
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.
omeowner Signature �
a
SECTION 5= DESCRIPTION OE PROPOSED WORK(check all aRplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)tJQ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] ecks [ ] Siding[ ] Other [ ]
Ilk
Brief Description of Proposed Work: r �� S�lq-iRS 2E'BvG�--
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6,4JfN& hoffWe_:and ,, ddition..to"ekisting housing, complete tt a fol"lowing:
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 onstruction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
rf
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 bgjow 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 ?a-'OWN ERAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR�'CON7RACTOR iAPPLIES FORiBUILDING PERMIT
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.
Print Name
Si 6<n ature of wne gent 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
Lot Size L ;
Frontage G
Setbacks Front % 7
Side L: /R: L: R:
Rear aid U f t
Building Height
O
Bldg. Square Footage / %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking S aces 2
Mviol,., e
&Location
A. Has a Special Permit/Variance/Finding ever been issued for/.on the site?
NO DON'T KNOW YES �'
IF YES, date issued: 2 — 4;� -0 2
IF YES: Was the permit recorded at the Registr of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does t 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:
of Northampton 5 0
ding Department t� !
JUN 1 9 )ru 12 Main Street S Sep l
Room 100
L -- --- - - orth mpton, MA 01060
''PECTIO
rl�,>Eia 3 58 1240 Fax 413 587 1272 P oS:te Pa
APPLICATION TO 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: fi
5����5?�'IQ Map I.of Uil#
fta Ac4 C c I 0 � "L_ Zone Overlay Djstri6t
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
z . Telephone
Signature
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 ermit applicant
1. Building (a) Building Permit Fee
14 ''yoczl ,cam
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) Check Number
m This Section For Official Use Only
Building Permit Number: V — Date Issued
Signature:
Building;Commissioner/Inspector of Buildings Date
File#BP-2002-1135
APPLICANT/CONTACT PERSON LAVALLEY MARK
ADDRESS/PHONE 207 SYLVESTER RD (413) 586-3779 Q
PROPERTY LOCATION 422 SYLVESTER RD
MAP 28 PARCEL 001 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid OVGJ
Typeof Construction: REPLACE KITCHEN CABINETS&REBUILD INTERIOR STAIRS
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
INF(jRMATION 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 on
Loo L
Signature of uilding 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.
AN a . � k BP-2002-1135
� w COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2002-1135
Project# JS-2002-1825
Est. Cost: $4200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 1080288.00 Owner: LAVALLEY MARK
Zoning:RR Applicant: LAVALLEY MARK
AT. 422 SYLVESTER RD
Applicant Address: Phone: Insurance:
207 SYLVESTER RD (413) 586-3779 O
FLORENCEMA011062 ISSUED ON.6120102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN CABINETS & REBUILD
INTERIOR STAIRS
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 6/20/02 0:00:00 1647 $6-0
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo