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parcel on whic' Le!s-e resides or Lnter,(L, to be, a orze or tvafam-i:y
f+`•V°777-a z:zacLed or de-ached struca-zes acctsscrr to s- Use and/o faz L- ct=e-
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I person W-z'
Z-C constructs more&t a= cze home in a-LXC-ye:---r FdrLcd. SL all not be corsid,ere.d. a
! ,home 0-.ref.
7-ht f.-F the C I V�Of Northam'-D-mr- anyperscr.(S) Who setk to.
L tie .7,4mdr e X-=Pticrl, tL--; a=Z 2- z--.
LZe=0-7ir ccr-z'.-u=-c= to b--a-7-,r-
tLat by doing so,y-c u beco=e re-s-D ensible for compIL-L-act-with state b ading cce,es
and regaLa-fous-
The
tc, izsrect Wori at v- --Frus sees, vitich inuclude foundatiom/footh2g-5 COffOre b2cIdUA
L42LOtube holes CDefore vour)- a rauz-h b-uildimz i=-ectib-a-(before work is
(if rf--cuLred)aa- ±g finn7 The
biuildizz- decZ7 requzres thesa inspections before the wcr<is cc celled; failure to
szt-ure Ca- tse M' S-Ve-Clions can result fn failure to Obtain a certiffcate Qtoccuoancv
E-tLe hc=ec-Wr-dr 0ZLIar L-ad, t moors(electnicc-17, plu—mbing&-gas) tLe
=es es 0 perrorm-Wo
LC -WEI be r--r cr--.b 1 e t C. r:alace sure tLat tLe t des bird tLeir pro-,e •
C-"' izs- th
-er---ts!a coon-juz on to the building pe zzed and that ey get their required
Laspectious-F 1:--e cf F'-e L,dr�-,dual tud es to se=e TL e pe=i7S and inzp ectiorS as
rem--e ytL,.e pFC.Tzt�, 1—:11 Suchti�, as and '
made
T r, -rd L-.e above-
u-nde ,= F
si--2turle re-questing ememption)
ca-1111 to scLedul-e a"TT r-- ed buileizz ispections necessary for tLe buildizz permit
issued zo r=e.
Office ofIn vesti,i1tZD3?S
600 Washington Street
=.. .
DEN-
DStD31, MA 0211
�t- WWW.mass.go v1dire
Workers* Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le!zibly
Name (Business/or_anizancn/In di vi dual): � ✓�f?��j r `/✓�%✓i �C%/ —
A AA
Crry/State/Zip: �:,����J�, ✓h✓� �;✓w 5� Phone : �i
Are you an employer? Check the appropriate box: Type of project(required):
!.❑ I am a em to era with 4. ❑ 1 am a general contractor and I
P y 6. ❑ New construction
employees (fufl and/or part-time).~ have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. 7. Renodeling
These sub-contractors have S. Demolition
ship and have no employees L-
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp_ insurance.? 10. Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
J.❑ I an:a homeowner doing all work officers have exercised their L mbing repairs or additions
myself. [No woHcers' comp. right of exemption per iti1GL frepairs
insurance required.] ' c. 1 52, §1(4), and we have no er
employees. [No workers'
comp. insurance required.]
`Any applicant that c."ecics box.TI must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
'Coeur actor--s tl;a cliecl<this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing worrers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Naive:
Policv r or Self-ins. Lie. ;r: _Expiration Date:
Job Site Address: City/State,/Zip:
Attach a copy of the workers' compensation Policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of_MGL c. 152 can lead to the imposition of criminal penalties of a
zz
fine up to S 1,700.00 and/or ore-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi,atiors of the DI_A for insurance coverage ver.'fcation.
1 do hereby cerziz urrrfz, tlirlsrrnrrs rr�}rrl erraltie e e=jE a the information provided above is true and correct
Date
IPi_cne . yi 6, . �y 7 Z,
L?v_�rzt_wri�_1his_ar_eat to h� om�ered bv.city or town "ciaL
_
ICity or Town: Per_nit/L.icense"
Issuin_Authority (circle one':
I r..;y- Cier:� '.. EleLtrca: Inspe t:;r PLm =n'_ lns e�icr
_.
Board o H,�2 t� _. Bpi iiiin'7 Department _. Lity,:�� u
6. Ot�tir
cne = i
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: -,z &
License Number
Z/1
Address Expiration 6ate
Signature Telephone
S.Registered Home Imorovement Contractor:-,-.
Not Applicable ❑
Company Name Registration Number
/// 711 C,
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....... Is( 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-vear 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
SECTION 5-DESCRIPTION OF PROPOSED WORK{check all applicablei
New House Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [5;4� Siding(01 Other[01
Brief Description of Proposed
��1iWork: /,V"/7f /L/f'i% '
;�1?r:�</iCG� /V�'GLf /r`�'�I�iv7?/L3s 7"✓)�C!-GJ.i.� r�-v'.Y ,7--��G'�f /?�'��vlc,./7 �>j�t/�i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If'New House attcf br addition:to existing'Fraus ncI 66MOIete the`fo[�ov+r ng:
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 cr Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck 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 CONTRACTOR APPLIES FOR:BUILDING PERMIT
5,) t'61 ✓1 /-w„/L i?- as Owner of the subject
property
hereby authorize ` J�'/?"Z J� y �✓r5� �
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of owner - Date
�✓� / ✓7�� J l/�'�✓j3C,f> 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
Yky
Signature of Owner,'Ageof Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size f .`/_. ....__. ____.�4..4f _.._
Frontage `
Setbacks Front
� E _ _..._
Side L:_/tL_ R. J_i_'
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
oarkine)
#of Parking Spaces
___._-- _ . . ..___- ....._ . _._. ..
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW I& YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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 0 NO Qj
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES i0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Sto-rm Wat&Management-Permit from the DPW is required.
a
IJepartrnent use only
City of Northampton stags ofPemit
Puilding Department Curtr Gut(]Diiveway t=ent
212 Main Street SerrrenlSeptiRvaTlab�ttc _
Room 100 Watr/tlVell P:varlabrltty
APP 1 8 2008 Nor'tbampton, MA 01060 TwaSetsofiStructitraPlans
phone 413-587-1240 Fax 413-587-1272 PlotlSifePlans.''
a
! °S Outer Specify
�.�
-- - 74PPLlCATl6N Tt-STRUGT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE_INFORMATI:ON
This section to be completed by office
1.1 Property Address:
�,� i c�i)T•C✓Z ` %j'I1`l Map Lot Unit
f!✓�✓_=/J! /)1 It zone Overlay District
Elm St District CI3 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addresss,
Telephone
Signature
2.2 Authorized Agent:
1,t?' 1V =T
Name(Print) Current Mailing Address:
-'I
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
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 `
This Section For Official"Use.Onl
-Date
Building Permit Number: Issued:
Signature:
_ -----_-- -- --------- -------
Building Commissioner/InspectocofBui mgs Date
File#BP-2008-0919
APPLICANT/CONTACT PERSON Larry Yentsch
ADDRESS/PHONE P O BOX 120 LEEDS (413) 584-4750
PROPERTY LOCATION 44 WATER ST
MAP IOB PARCEL 077 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
juildin2 Permit Filled out At
ee Paid
Typeof Construction: Repair Porch
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 FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
ppioved 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 Commission Permit DPW Storm Water Management
Demolition Delay
aY zz, 0,
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.
BP-2008-0919
dis#: COMMONWEALTH OF MASSACHUSETTS
r k - CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
c tzgmL BUILDING PERMIT
Permit# BP-2008-0919
Project# JS-2008-001376
Est.Cost: $2800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Larry Yentsch
Lot Size(sq. ft.): 11499.84 Owner: KURZ EDWARD A&ROBERTA
Zoning: URB Applicant: Larry Yentsch
AT. 44 WATER ST
Applicant Address: Phone: Insurance:
P O BOX 120 (413) 584-4750
LEEDSMA01053 ISSUED ON:412212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-Repair Porch
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 4/22/2008 0:00:00 $50.00888
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo