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17A-220 (4)
A•l 'A y� rr-I M, a i � � i i I i i i E ', � s � � ��� t�'\\. 3 � `\` ,�\` 3 ��� �. ,..... ; � 11 � 1 ':` # ` \�� � \y � ,\ 0 �� �� �', y t ; I d i � � F ..__... {(� _ 1 � r i i v ((� t��,, �°�-�,. 3 _ ___.. 3� �` �'._ � p �� �__ x ,' 9 . ��_ �� __ _..� /� r .._.._. _ f t ` R• ••� ' ,+'•�lyy r�`"�.l"» �.ul: ���� y •+�I��»y� �RAi , � ��'•t '�" �� ��}f�`�y� • `"l M''r `: �►���1V1� �+T •l��••# t t �IS)�y • +. i " f";rl' i jyls t � �•y 4 • ..r'� • +R i CA . R a ♦r' ♦A • r M� «►1 4.e ,4 C _ ta IV T - y�q n � � 4 Zj ZY) . , 'Al moo ' f7ooK Suf fe*7-3 11 x xr T.rw c K*W 'rd 8 Io1V6 w/SoOv* Spa cc Tit� of fl z gB f�lxast:chasctta' r v+ - m DEPARTMENT OF BUILDDZG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSA'T'ION INSURANCE AFFDDAVTT I, (Iicenseelpermittee} with a principal place of business/residence at: (phone#) (s[reet/ci ty/stare!a p) do hereby certify, under the pains and penalties of pegJury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Daze) ( ) 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 Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (F-\piration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional lhxte if neccuary to inch do information pertaining to all ooutna rs) O 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 aware that while bomcow-D=who employ periaw to do mal.�coast,,v ca-rah work on a dwrlling of not more than tbtue units in which the homoowncr rexidca or oa the grounds appurtenant thsrcto arc not gczxraily oomidacd to be employers under the wockct's ooapcmatim Act(GL152,ss 1(5)),application by a homcownrs for a ticcase cc pcamii tnay cvidcnm the legal etabu of an employer under tho Workees Compomaiion Ad - I undaatand this a oopy of this Qatcmcat may ba forwarded to tbo Dcpnrtmml of lndwb i al Accidcsb Of.of 1. iX O for the covets go verification and that failure to scatre coverago under sodioa 25A of MGL 152 can lead to the imposition of aim4W peaalties oomistirtg of a fine'of up to S 1,500.00 and/or imprisoam of up to one year and civil penLwcs in the form of a Stop Work Ord-nerd a firm of S 100.00 a day against mec For�Numbcr o°ty p NialA Lot# Signahtre of Liccnsedpermittee e _._ G ' ONSiR3t1C'i ION 5EIZVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder License Number Address Expiration Date Signature Telephone . r .. a Not Applicable. Company Name Registration Number Address Expiration Date Telephone SEC,TION 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 affidE 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)familic 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( 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 Local Zo ' g Laws 0 $tate of Massachusetts General Laws Annotated. Homeowner Signature IA r �SECTON ::D SCR P�-I ° ;�F�PR POSED�WOt� clieck��a �a licable � �'� ; i 1W WIN, New House ❑ Addition ❑ Replacement Windows Alteration( Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition)o New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovati g unfinished base t Yes No Plans Attached Roll ❑ - Sheet❑ � � �(.X r�.S�wry '� ' t r kill-M FIfNe t o I e ant "duo` additio0-oezistingtousin ,ucompleeth `f0�1l.oi ON- 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 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? OWNER AUTHORIZATION -TO B,E COMPLETED WHEN OWNERS ACENTORCON7RACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject proper hereby authorize to ac my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I ��� Authorized Agent hereby declare that t e 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. G Print Name 43 _ Signature of wner/Agent Date i 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 lot) Setbacks Front r^j(7 1 8T 4fi Side L: a I R: L: R: j Rear i Building Height Bldg. Square Footage % d Open Space Footage % J (Lot area minus bldg&paved CJ parking) Pi #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: r t . �� .a 4 a, � �, .. .. h' .. � .. � .. Y �� a :� ^" 4 TY �, � FA £ °' „. (t. t 1 � rP I l} r ilty of Northampton ' O'uilding Department Li�MAR 202 12 Main Street . a Room 100 ©fBUILDING't� 1, ''Nort ampton, MAO1Q60 eatNAMP1flN,I�' 0``'F�' 587-1240 Fax 413-587-1272 t, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION'1-SITE INFORMATION This section Lobe com ( ted byffrce4e 1.1 Property Address: Hot R S Map Lot L! t �--�- — Zone �`��O�erl�ay�b� trt _E&j?E*W4!0 OZ .................. x Etm St. District CB Dsfr�ct" SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam GA - IF t) Current Mailings _ �Or'� jo-,;/` Telephone Signs re 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 com le ed by ermit applicant 1. Building T 4,11 � (a) Building Permit Fee 2. Electrical UUVV A (b) Estimated Total Cost of Construction from 6 1 Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) . OLTO Check Number This Section For Official Use Only Building Permit.Number: tol'Sa r 7 Date Issued: Signature: Building Commissioner/inspector of-Buildings, Date File#BP-2002-0785 APPLICANT/CONTACT PERSON CORBETT FRED T&HELEN T&PAU ADDRESS/PHONE 172 NORTH MAPLE ST (413)586-3005 Q PROPERTY LOCATION 172 NORTH MAPLE ST MAP 17A PARCEL 220 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid ;2970 25 Typeof Construction: REMOVE OLD SHED&REPLACE W/22 X 20 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 Commission Signature of Building Of icial 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. 172 NORTH MAPLE ST BP-2002-0785 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-220 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: shed BUILDING PERMIT Permit# BP-2002-0785 Project# JS-2002-1308 Est. Cost: $5000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sg. ft.): 2 169 2.88 Owner: CORBETT FRED T&HELEN T&PAU Zoning:URB Applicant: CORBETT FRED T & HELEN T & PAU AT: 172 NORTH MAPLE ST Applicant Address: Phone: Insurance: 172 NORTH MAPLE ST (413) 586-3005-0 FLORENCEMA01062 ISSUED ON:3121102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE OLD SHED & REPLACE W/22 X 20 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 3/21/02 0:00:00 2970 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo