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17A-306 �� Rl �b �A � 4-�t1H1�{pTO Boo °fl Gitf of wart flttliipto11 � 6 �xssxci)nsctts m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street < Municipal Building Northampton, Mass. 01060 'WORK-ER'S COMTENSA'I'ION INSURANCE + + AVYr P,-L(— �,� L(-� C I � (li cemsee/permi tree} with a principal place of business/residence az C,o 'l1� (phone#) �(" o-p' �� (strce-Uci ty/statd2i p) 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 worEng on this job: (Insuranov Company) (Policy Number) (Expiration Date) O 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 Compairy/Policy Numb--r) (Expiration Date) +r (Name of Contractor) (Insurance Company/Policy Number) (Expir<tion Date) (Name of Contractor) (InsZtranc-- Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comp-ny/Policy Number) (Expiration Date) (atiadr additional s!XrJ ifr'. c ry to iOc L-;r i:fonnition putaiuir&to all ocatradors) ( I am a sole proprietor and have no one worlrino for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homcowixrs.a6o employ p<-o�to do Qalrt zcc s' Goa or repair work on a dwcl g of not moce than droo units in Minch t5e homeowner rrsida or oa the uou u:s zppu naat there.)arc ocA 1-c:xially eoaridcrcd to be employers under the worker's cca*cc=tica Act(GL152,=1(5)),r,^ izitien Fry a hoaico%Nna for a l cease cc Pcr:ni:ra•^-y c%i6moc the legal ctahra of an employor under tho Workoet Compcc:m on Act I undentand that a copy of thiz rtatcrneut aray bo forwarded to tho Dejxutmart of Ind d Accidcnty Ofroo of Ic5ur*z'co for the ooval�vaificadoe and a utt allure to&==covetngo tmd r sectica 25Aof biOL 152 can lad to tho impositiou of aiminal Penalties ooasistiug of x fine of up to 51,500.00 atsd/or imruisonaxat of up to one yrar and civil Pcanttia in Sc form of 1L Stop Work Order and a f=of 5100.00 a day against rw- For dcput'n—W tuo oaly Permit Number rot 4 _ r Signatize of Liccnse&permittce e i SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed /� Constructions Supervisor: J Not Applicable ❑ Name of License Holder : l a S `� E C l 5 C j Ste/ License Number P �k �I.S Address Expiration Date CNCS(E, ��L J), Signature Telephone ,� - - V 4,,4' �i ,. �.. N 0 t Applicable ❑ .Reg siterei.Home.improvement Co`ntractoi.R .« �. �. . .._. ._ . JA 3 Comp ny Name Registration Number IIII �(Gz 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...... ❑ 11. Home Owners=Egemptiori 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 ' r SECTION'5-'DESCRIPTION`011`-PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [�Q Siding [ ] Other [ ] Brief Description of Proposed Work: S (L S+ Dt(-C kE hr` O Alteration of existing bedroom Yes '►� No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes ✓ No Plans Attached Roll ❑ - Sheet❑ 6w ' the follwin , f ue a 't g og: 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 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 AN -�)4tvy 4,1i a t�L-Y `DES/N , as Owner of the subject property hereb aut riz 1, I � S 4 ^r L(� C K_ to act on my be alf, i all a t as r lative to work authorized by this building permit app icatio . Signature of Own r Date I, C C(.J �LC-A C 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. V'4 LCr� ClI% Print Na 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 � Lot Size Frontage 1 0 r I ° i Setbacks Front Side L: " S R: L: R: �S Rear Building Height Bldg. Square Footage c v % ti(L4 Open Space Footage 0 (Lot area minus bldg&paved � parking) #of Parking Spaces `1 Fill: A volume&Location) A. Has a Special Permit/Variance/Finding/ever been issued for/on the site? NO DON'T KNOW t,/ 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: Q ._...-- vvjX f Northampton BUil l g Department Curb u I$ Y w , MAY 2 2 2002 Main Street loom 100 Wa er/Well , Wtha pton, MA 01060 T WO,gels r� £ r c r an „ RYtphyotSe'P` 240 Fax 413-587-1272 P16 te Plans APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION This section fo be completedby office 1.1 Property Address: " ' / , (.&CIQe�T � fUC Map.. Loft q Zone. h OverlayDistnct, _ 4 N:. CB Elm St. District 1if" ct -• SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name( rint Curre ailin Add ress: Telep on _ Signatu e �r — � S 2.2 Authorized A ent: VA L-�,� Na rint) p p 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 f S6 (a) Building Permit Fee 2. Electrical _ (b) Estimated Total Cost of Construction from 6 3. Plumbing ' Building Permit Fee 4. Mechanical (HVAC) Q 5. Fire Protection 6. Total =(1 + 2 + 3 + 4 + 5) SDu Check Number This Section For Official Use Only Building Permit Number: )p--Z©02 -/azZ Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2002-1022 APPLICANT/CONTACT PERSON CHARLES VALENCIK ADDRESS/PHONE P O BOX 565 (413)296-0226 PROPERTY LOCATION 77 HILLCREST DR MAP 17A PARCEL 306 001 ZONE URA 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: ADD 516 SQUARE FOOT DECK TO REAR OF GARAGE AND HOUSE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 063354 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOPLMATION 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 Commiss' n 6 leerl�6 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-2002-1022 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Buildlnl? Categ_ory:Deck Addition BUILDING PERMIT Permit# BP-2002-1022 Project# JS-2002.0890 Est. Cost: $7500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: CHARLES VALENCI K 063354 Lot Size(sic. ft.): 21823.56 Owner: KESIN HOLLY B&ANDREW M Zoning:URA Applicant: CHARLES VALENCI K AT: 77 HILLCREST DR Applicant Address: Phone: Insurance: P O BOX 565 (413) 296-0226 CHESTERFIELDMA01012-0565 ISSUED ON.617102 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD 516 SQUARE FOOT DECK TO REAR OF GARAGE AND HOUSE 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 6/7/02 0:00:00 2680 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo