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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
`VOPUCER'S COMPENSATION INSURANCE AFFMANTIT
(licensee/permittec) -
with a principal place of business/residence at-.
(phone#)
(streei/ci ty/stal e/2�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 working on this job:
----(In_=nc- CoMp_any) (Policy Number) -- - (Expiration Date)
( ) Imi 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) (Lnsurance Coinpary/Policy I�tumbcr) (E.xp:ration Date)
f
(Name of Contractor) (insurance Company/Policy Number) (E�olm,bon Date)
(Name of Contractor) (Insurance Company/Policy Nrunh,�r) (Etipindon Date)
(Name of Contractor) (Insurance Company/Policy Numboi) (E:,,T,,iration Date)
(atLadj _Fntcenuy to include iafo'aution pats;;: r,.�to all oxltractof3)
( ) 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 awsrc that while homcowoc"Nvbo cmploy pczo u to cio m.« �n ccr:..nn�on or rc?a r work on a dwcl i g of
not more than thrca='s is villa tba bona mcr m'&a or 006C q-eucws zppurtcnani thczdo arc rxX Ccrxrally cocsidcrcd to be
cnpl0yc13 under tho v-zk&s ccavcm4ca Act(GL152,"1(5)�appl rat7on hY a hoatcoavcr far a Lcar_sc cc permit tnay cvidawc the
legit ctatas of an employor undtrthn Woricoee Comp oration AzL
I understand that a copy of this ctatcmcod may be forwarded to tbo Dcpartmcat of Induatr ti Aecid-,IY O1hoc of 1--noa for tho
covcagc va-ific Itioa and that flillue to scatrc covcrago under swd oa 25A of MGL 152 can lead to tba imposition of au in l pcaaltics
comisting of a tine of up to S 1,500.00 and/or im{n isotmxat of up to one year and civil pa mitia in the f«m of it Stop Work Ord--mad a
find of S 100.00 a day tgaiast m-
11 Foc&'Virtr�ml wio oaly
Permit Number
map;{ Lot 4
Si of Liccnscelpetmiticc --
`+ At .
w
SECTION":$ CONSTRUCTION SERVICES "
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
r e _ � E Not Applicable ❑
9 Regts�ered # e u rnen h ra"ctor � ' �._a , rN
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...... ❑
oml Owner ExRobon
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 buildinV 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 ass responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and L al Zo , g ws nd State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTIONI DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [. Siding[ ] Other'Q
rr
Brief Description of Proposed Work:_ Ova' _� a�, � �^T � �"Ok
Alteration of existing bedroom Yes_,V— No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a'If New Wd se an i or addition to eVxi'§ting-Kdif >7,17 corriplete the:followin
!, a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit:_ Number of Bathrooms
i
c. Is there a garage attached? D
d. Proposed Square footage of new construction— Dimensions
e. Number of stories? rZ — k
f. Method of heating? L'4CAV _ (9L'L..— _ Fireplaces or Woodstoves ►"� Number of each
g. Energy Conservation Compliance. _ Mascheck Energy Compliance form attached?
h. Type of construction 110"K4r&-e_.
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
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 a e
Signat re if 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 Z
Frontage
r
Setbacks Front
Side L: R: L: R:
Rear
Building Height 2
Bldg. Square Footage Cr�Q Sf %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parkin Spaces Z__
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO /K- 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:
thampton P
(` t; u i partment G r u ID a
-'--�"` 2 i 1 I Street 9 t H
R. 00 W ,
Gtl ! ARlatamp on, MA 01060
pone 413-587-L 40 ax 413-587-1272
4et Spectfy�� t
AP 1-ICAT d C RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION_1- SITE INFORMATION
This section to be completed by office'.
w.
1.1 Property Address: `
k �� � Lk -- a c) C Z Zone Overlay District
Elm St. District CB i2istrict`
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
—
3-r,'k of ka vx Q o.,nCLe. V _ q6 IS
Name(Print) Current Mailing Address: �i 3 f
_ 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 ermit applicant
1. Building ?jlav c� (a) Building Permit Fee
2. Electrical lx� (b) Estimated Total Cost of
_ Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0775
APPLICANT/CONTACT PERSON HART REBECCA F&JONATHAN
ADDRESS/PHONE 96 CHESTNUT ST (413)586-2376 Q
PROPERTY LOCATION 96 CHESTNUT ST
MAP 17C PARCEL 086 001 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
T_ypeof Construction: NEW FOOTINGS FOR EXISTING FONT/SIDE 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 FOA'�OIWON ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF PRESENTED:
ed 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
�-
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.
S
.,96ESTNUT ST_
BP-2002-0775
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV Block: 17C-086 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0775
Project# JS-2002-1286
Est. Cost: $300.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sic. ft.): 11107.80 Owner: HART REBECCA F&JONATHAN
Zoning URB Applicant: HART REBECCA F & JONATHAN
AT. 96 CHESTNUT ST
Applicant Address: Phone: Insurance:
96 CHESTNUT ST (413) 586-2376 Q
FLORENCEMA01062 ISSUED ON.3115102 0:00:00
TO PERFORM THE FOLLOWING WORK.-NEW FOOTINGS FOR EXISTING FRONT/SIDE
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/15/02 0:00:00 754 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo