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17A-077 (3) • ��ttvrnT Z° R @ U If�I of �'Torf 11ui1ipjoi1 _ 4 E _qlasanchnsclla ; DEPARTMENT OF BUILDING INSPECTIONS — 212 Alain Street ' Municipal Building Northampton, Mass. 01060 WOMCER'S COMPENSATION MSURANCE AFFUMVIT 1ccnscfr 11) e) principal place of business./residence at: __(Phone:=) 5� J (strc ty/stair-In P) do hereby certify, under the pairLs and penalties of perjury, hat i ( ) 1 am an employer providing the following \vorlter s colnpensanon coverage for Inv elnplovices work�ang on this job CL 07 (La=nc2 Corsr,,) (pclie:? u Il cr) (Expiration Due) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listen below who hive the foiloWU' P worker's conoensadon oohcies: (Name of Contractor) (Insurance ComPanyrPouc, Num!Yr) (Ex?ifauon Date) — (Name of Contractor) -- Ras-d ancc CotnDanv/Polio Numccr) (I x'oLm6on Date) (Name of Conrractor) Gasurance CompanyfPolicy Namb r) (Expiration Date) (Name of Contra(nor) (Ii15U=C—_ Company/Poky Number) (Expiration Date) (auach additional ixC(if ncocur:to incttldr infortni.�oa pertnin:ng W ell 0000-�) ( ) I am a sole proprietor and have no one working for me. ( } I am a home owner performing all the work myself. NOTE:plcsc be aware thn wUo homoovmcn wbo cmplay Pc-lo=w do m=;..,caan*r,was:j 1, oo or rcpau Work an i d. _11ing of ao(more than thma units in wfncb the bomoor w rradcr oc oc the Bounds zppad a..n6 thccto oo(generally wanda-cd to be employa3 undo the wm+&i oompcssdion Act(GL152,s 1(5)�appticaboo try a bomcoavcr for e dame oc permit may evidco-tl:e Ic-pl ctxttu of an employe<under dw Wockzet CboA>oosa Act I undcruaad chit a oopy of thu eat® may be fo�nrdnd to the Dopartmcnt of lndtu'sinl AaadearJ Offioo of In;v—>oo for the look eovaxgc vcnfrcrtioc clad that f_iltac to tocurc covn-,' a under socxioa 25A of 1.(OL 152 can Icad to the imposition of aimintl pcaalUcs oomiumg of a fine of trp to S 1,500.00 androc imllriso�of tap to ooc ycar end civil pm ilia in dx form of a Stop Work Ordcr amd a fim of S 100.00 a dly agniml me Foe dcLucme�r.l t1�e ooly � Pc/remit Number . 1"41 Pn Lot�1 - ignatu of Li hairier SECTION 8-CONSTRUCTION SERVICES L Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Corniany Nanib Q Registration Number Q G - o — 3 — � /U� e Address r� Expiration Date CC" �Gvyy\, W elephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(S)) 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. I-Signed Affidavit Attached Yes....... ❑ 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-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. V Homeowner Signature ZI 2iz ( . D I, F; 0 e Iicabie F use_T1177 placement Windows Alterations) ❑ Roofing ❑ Doors ❑ry Bldg. w Signs [ ] Decks [ ] Siding[ ] Other[ J Brief Description of Proposed Work: o� f'� o,v Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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? 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 -7,c�✓�-+ as Owner of the subject property hereby authorize to act on my behalf, in all matters rela ve to work aut orized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare t at the statem nts and information on the foregoing application are true and accurate, to the best of my knowledge and belief. igned under the pains and penalties of perjury. Print Name ys 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 Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location 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: Gity�f­Northampton Fphone difti rtment a!in treet Room 100 Y —rfbrMW-n ton' ra A 01060 p 413-587-1?40 x 413.587-1272 APPLICATION TO CONSTRUCT-, , REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This S Yc:n tp b com feted offiG�r 7—wnt�--� ► 'I o-�—�— cne erays'stri+# Elm St, Dkirict :blstrict" SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT : 2.1 Owner of Record: F-v-QY,c-r s W, OcL yA w e_ l f ame(Print) Current Mailing Addr ss: .{� P Signature Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: —�— Signature Telephone — 0 '3 SECTION 3 ESTIMATED CONSTRUCTION COSTS A Item Estimated Cost(Dollars)to be Official Use only completed by ermit applicant 1. Building 000 (a) Building Permit Fee 141- f 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) Cheek Number Q t Thin Section For Official Use Only Building Permit Number: -d-& 1 Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2002-0964 APPLICANT/CONTACT PERSON Larry Paquette ADDRESS/PHONE 40 East Green Street (413)527-6375 PROPERTY LOCATION 26 CAROLYN ST MAP 17A PARCEL 077 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid TVeof Construction: INSTALL REPLACEMENT DOORS&WINDOWS ON ENCLOSED PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 100679 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF0RMATION 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 Stre ommission 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-2002-0964 GIS#: COMMONWEALTH OF MASSACHUSETTS �:.t! .077 CITY OF NORTHAMPTON Lot: -001 Permit: B u i i d i ng Category: BUILDING PERMIT Permit# BP-2002-0964 Project# JS-2002-1563 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Larry Paquette 100679 Lot Size(sg.ft.): 9888.12 Owner: CARDWELL FRANCIS W&BEATRICEH Zoning.URA Applicant: Larry Paquette AT. 26 CAROLYN ST Applicant Address: Phone: Insurance: 40 East Green Street (413) 527-6375 Workers Compensation EASTHAMPTON MAO 1027 ISSUED ON:5113102 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOORS & WINDOWS ON ENCLOSED 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/13/02 0:00:00 3028 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo