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1)EPART PENT Ott LUILDR\IG INSPECTIONS
212 Maul Street ' Municipal Building
Northampton, Mass. 01060
NVORP EWS CoOrII)rNSA110IN INSURANCE AFFIDAVIT
`�-�-Pr----
(l;�n���.� ---
v"1111 a/p�ri/ncipal place o?business/re�i�e/nice at. n
do hereby hereby ccl�ii��; unre; ?h'� n<:iils and penalties of ,x.rjuly, :flat
O I am an employer providmQ' the f0llow11'1" V,'orip:el's compensation C'OVCIt:.'.c
eluplovees working on this job.
(Ins=ic: Comp-ny) - - -- C'ciic',Nu_nbcr) ---- - r.i n Datc) -
I cam a sole pI'OUilc?(DI :?,eilcCi� COL1Li�CtOt 5i homeOwne. (cllcle Ont) amC li3V llllf d
the contractors listci Deio',v ii�i10 il�'1 the fOl C�';ti1� w01-Kef 2s comi)ensanf-1 ON1C:�S
(7`:f11I1C Of Cmltr.lclo—) ..-�,!I1slrI�1C" L�OIIin"::i�ihOl1C,}' �VtLISIl�:Yr) -- -il�?, i1;1cI': Date)-
__---
(Narlic of C011U2Ct0r) lnsu�,:r,c C o_�_t sl�i?c!!�' NL!m r) (I_. _. ...' Da"c)
(Name of Conu.Actor) �i,��!r uic (� at,�Itolicv Numlxr) 1 ate)
-- (Naive of Conti-actor)- - ZnsL.r�slc Comr r;y;Policy Num�r°r) - (I.)1r;i,:tic:: Date)
(etl�dt u1'Si5mil:axct tf nc,cv:-. •- r_i_::4 :::[crc n:i icc:r*.:tain:r_r'_;ail
XI alll �l SOlC l;rOp11 ��)i (_'?r;I have Ilo One v,'olhlil for nie.
C ) I
am
NOT:p!c sc tc atruC tt:at s',tiic kx<; o.�,m t+:h�<:;play Ir-;:, 4 d>ma c Lacs ar�n m cr::f>air
not nice than throo unite in u{ dt::x h� •ar r rczi cr a:"I ��i,� yurtr,•nt thcrcto a c txt[�crxrally o_r•�c:r:�:�
em=ployers under tlx 1(S)),adir�tic.:by n honicot��r fur n Lar_x ee F-ra:::r :�.-tee C:�
Itsal ctatuc of an c nvloyot under tf.o W"ki "Co v;xrr lion Acx_
I ua,&r tared thst a copy of the x ctatci: 1 mAy La Ix�u iod to tl»Dcynrtnaci of Indcuttid Aoidrntf Ofroo of!::;a_a for tha
oovcragc vcrificatioa and th:t Ellu c to f"Curc cbcrrcr ucd r 14c,n 25A of MOT,152 can lad to tho imposifioo of cry i:-1 pcc lll:cs
oomutmg of e Eric of up to S 1 500.00 aa.'cr ice,ri xtnk r`S of up to cn- civil perultia in dx form of a St ,'
frtooCSt00.00 t dty ir_in:l r.
Fcr dq;utrtraCnl u.c oily'
', Pcrmil Nulnbcr - - -
I
Si�naturc of Lug .tide un�ttrr-. �?)�__;_ j E
SECTION 8-ICONSTRUCTION SERVICES
8.1 Licensed Construction--Supervisor, Not Applicable ❑
Name of License Holder : / C) lti( �i' Nit ! ���� oe t DD�
License Number
if S� ?� 4p 1 .�.� � l �� �7a. D/ors S
Address Expiration Date
Signature Telephone
F±,W- teed I�bme mprovement=.Contr'actor:
� : F. ° R a LIN Not Applicable ❑
JJ
Company Name Registration Number
Address r Expiration Date
Telephone
SECTION 10-I'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...... ❑
+_a0 n
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
SECTION 5 '15ESRIPTIONOF PROPOSEDAWORK(checkrall applicable)
f*A[ue�,*hfmuawn ,m ;x�, J.w! rtvn+ ?�eren xm,rx,vxm K.,. a enbv r r S .111'44.'
New House ❑ Addition ❑ Replacement Windows Alteration(s)Jr Roofing ❑
Or Doors ,le
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ ]
Brief Description of Proposed Work: enGjdSe brev-Ze JAy M 0Vt 9_t' (' Z" °'c%�'%1ns roe k", AJJ 0 �Mvdroo/P^
Alteration of existing bedroom Yes X No Adding new bedroom Yes �e' No G.Sftr
Attached Narrative❑ Renovating unfinished basement Yes X No 6C'A
Plans Attached Roll 0 - Sheet 0
6a: If'New7,,t se antl or aiiditJ10',o &NAinfr.<:Housing:co ij lete;Ah6Ffo I 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 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 7aF OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWN ERS.AGG NT OR CONTRACTOR'APPLIES FOR BUILDING PERMIT
1, 90'\)J as Owner of the subject property
hereby authorize To v\ West 1;A aer _ to act on
my beh f, in all at s relative to work authorized by this building permit application.
Signature of Owner Date
I, (,- d- `�b114P.1 as Owner/Authorized Agent
/ �IL1 �s�`
hereby declare that the statements and information on the foregoing application are true and accurate, to Me es 6fim'y
knowledge and belief.
Signed under the pains and penalties of perjury.
Yl (k 45 4/e--s —
Print Name
Date
Signature of Owner/Agent
t
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 2') 33 3 : )) G
Frontage I q i • �)L !
Setbacks Front 7�` -7 � ' df O
Side L: R: ~' L: a o R: 3 y
d
Rear { ' V7)
) O
Building Height
Bldg. Square Footage 3 S� /� %
!o
Open Space Footage %
(Lot area minus bldg&paved 3'�;G7 q �y 36- 9/L/
y 1 0
parking)\
of Parking Spaces
Fill:
volume&Location N v44
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:
j
l
City of Northampton S at s
n�
.1 department rb
Q U
Oin Street Sewer p•i d a
100 a er I
JUN 1 3 2W3
i thar+ra.pitgn MA 01060
phone 413-58t-1240 Fax 413-587-1272 �fo /Slte Pa
--� Other Spe0
I APPLICIOhO NE ).UCT,A11TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION_1 - SITE INFORMATION
This section to be completedby office
1.1 Property Address- !/J / W` r _
rill
Map
M!� � 1 � � a s Y
R o�._ e vi C e Zone Overly Distelf ct
Elm-St District CB-District
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
!Jcr; Ark ! ume�w W iC I/L/ �L,r't^r�e1d L,ne� Florencel'�IA d I D L3
N ie(Print) Current Mailing Address:
yi 3-S8 7`"��/ 6 —
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 ly
2. Elecirical (b) Estimated Total Cost of
-7y 0 00 Construction from 6
3. Plumbing v Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 +4 + 5) (a`� 5-0 U Check Number Q a
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1142
APPLICANT/CONTACT PERSON TOM WEST BUILDERS
ADDRESS/PHONE 164 SOUTH MAPLE ST (413) 586-1812
PROPERTY LOCATION 44 SHEFFIELD LANE
MAP 17C PARCEL 121 001 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 7 d 7 U
T_ypeof Construction: ENCLOSE BREEZEWAY RELOCATE KITCHEN&DINING RM,ADD OFFICE,
MUDRM RENO MSTR BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 001001
3 sets of Plans/Plot Plan
THE FgELOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1 ATION 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 mmission
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.