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17A-227 (2) ��ttntrrT of P0111jullip toil H �lxsirtchnccIt5' DEPARTMENT OP DUILDFNG INSPECTIONS — 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORl IZ'S CO\TPCNSATION CNSURVNCE AF DAVIT (l1 ccus;dpern»t tcc) \vIth a principal place of businessireside(3cc al: - - - (sn-1~.t/ci ty/statcrzi p) do hereby ceraf);, under the pains and penalties of perjury, ?hai ( ) I am an employer providing the folloWing worker's C01 cnS�0 cov for uty ernplovccs wor'.�ang on this job (1as- �n. G C o 0 v) (Polk: N. 1) -- (E:pir oon Dale) ( ) I am a sole proorietor, general contractor or homeowner (circle ore) and hEve hired Lhe cones actors lisiej below who h2ve chc following •,'/ork-.r s CoDDe isznon pckles: (l+IIt'i]C Oi COi?L::'.CiO'1 (ln�llla it C;. Coinpanyoi GUc-,' 1�t�n•rr:) l!:>.i)1;.!G0:! 1�alC)' (N;nc of COUI TaClor) jnslfancr. Comoaa`vPohc-,, NU-Mc�r) Date) (Name ofCoanacio;) (tasivanc: Compao)'/Policy Numbr) (E-\piruon Datc) (Nainc of Contractor) (Insii=cn z Compaay/Pchcy Numb r) (L=xpu-auon Dair)- (r.aad3��ocil s!uU if occcv� to ux!uc�i�fc�-i�_ioo pert�:ains to.L oo�r..r_.o:-�) ( ) a sole propnetor and have no one working for me. I any a home owner perfo[Toing all t-he work-"myself. NOTE:plr be nwarc t1.••wjj bccrro , to employ pcwns w da,-,;. �,-�cc-✓--.�c�oo c rcyau.�orK oo�d..c1L.�or ao(a-oce Lira L`ro:tars in«aid)dJ, or ca the Qo,o zvTurt,a [�zny ox-d—d to be caiployc-z uDdl--Lhc«o irrs s rTk --gym iw(GLi 52n 1(5)� pplirstioo by n homcoa a fcr c b.csr-<cx F fTm n-y�LL-c Icg�J—of—crgloyer and 1 o Wor4<! Coop xia.-Lwa i1cL (undc,-L—d dw a oopy of this er>�mny bo to tba Dcpunmcot of j—i— fid f l—for the coven gc vcriGc3Loa"t11--i L•iitxc to soar c tovcnq� under soctioa 25A of h(01-152 c n lad w the inTJO ca of mmiasl iy- a a 000niz of a riot of up to S 1-500.00.nd/or arxfvisooment ofup to ooc year r_nd ciNii pmj1-�a o be form o(n Stop Wort Order nod s fun o(S I00.00 t d_y tptiast tl For dcp•run=�)u+c only r �C perm,Numb- Si tun:of LiocrtscrlPcrmittcc —T��e sECT1aN�ca�1TRMJ7lt3NSE�V�cES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9:,, n r r F4�: ...;, Not Applicable ❑ 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...... ❑ 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 Massaohusetts 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 Signatu SEgn!Q -©ES R PT 0 OF P 0 0 ED WORK the k I'a licable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ / Or Doors ❑ Accessory Bldg. ❑ Demolitionw/1--, ' New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Lze y;) Fin vru4,D P100 r9.1Vla/G 7.6 _R197 SS 'sas- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll❑ - Sheet o 6a'.1f N6ri h urs`+ of addition ta,J e fstrn =hausi;n n com_...le;, a th ;#ollowin' ;: a. Use of building: One Family Two Family Other a. 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. floodpiain 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 AGENTiOR'CONTRACTOR APPLIES FOR BUILDING PERMIT 1, 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 I, as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my !i knowledge and belief. Signed under the pains and penalties of perjury. l iPrint Name 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 I ' 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: ,� t .. _ .. _,-., .. ..._n �)�, J _. , A a 2 mpton E D Udik Aicn� )(tment 212 reet MAY 2 5 ° o ort amp A 01060 413.587-1272 DEPT OF BUILDING INSPECTIONS APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION This sectloi to be completed b+office 1.1 Property Address: f5 3 ' � ���� Map Leo# Una 'x !=/n /ZyC1. � Elni St District= CB District 4 . SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ s / /d —W /fix-M 9 —' 1,77 Name(Print) Current Mailing Address: Telephone ,/ �u ,,3 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 2. Electrical (b) Estimated,Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = G + 2+ 3 +4 + 5) Check Number This Section For Official Use Only. Building Permit Number: Date Issued: I Signature: Date Building Commissioner/Inspector of Buildings File#BP-2001-0980 APPLICANT/CONTACT PERSON BENOIT JAMES A&KATHLEEN E ADDRESS/PHONE 111 LAKE ST (413)584-3516 Q PROPERTY LOCATION 11 I LAKE ST MAP 17A PARCEL 227 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 lypeof Construction: DEMO INGROUND POOL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THVOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § —w/ZONING BOARD OF APPEALS 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 Conservati ommission Permit from CB Architecture Committee 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. BP-2001-0980 GIs#: COMMONWEALTH OF MASSACHUSETTS t e'; CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: demolition BUILDING PERMIT Permit# BP-2001-0980 Project# JS-2001-1753 Est.Cost: Fee: $10.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size( q. ft.): 19732.68 Owner: BENOIT JAMES A&KATHLEEN E Zoning URB Applicant: BENOIT JAMES A & KATHLEEN E AT: 1 1 1 LAKE ST Applicant Address: Phone: Insurance: 111 LAKE ST (413) 584-3516 O FLORENCEMA01062 ISSUED ON:5130101 0:00:00 TO PERFORM THE FOLLOWING WORK.DEMO I NG RO U N D POOL POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 5/30/010:00:00 733 $10.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo