17A-248 f �J
MAR 15 2002 !
E{j
J�
�.tttA!-lP�O
Boo °- Git� of NartijaIItptoll
fl
a B �XSaltCllttSfllE'
x
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE ATTMAWr
(licenseelpermittec}
with a principal place of businesslresidence at:
(phoney#)
(str�ei/ci ty/statE/zi p)
do hereby certify, under the pains and penalties of pc ury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Ias cr -_ Company) (policy Number) -- --- (Expiration Date)
O I arr a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compen-s bon policies:
(Name of Contractor) (Insurance Company/Policy Numkr) (Expiration Date)
(Name of Contractor) (Laurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoGcy Ntunber) (expiration Date)
(Name of Contractor) (Insurance Com-v_uy/Policy Number) (Expiration Date)
(attach additio al shtct if ncecau to include informstioa pertaining?:,all occdxndors)
O I am a sole proprietor and have no one working for me.
b<'I am a home owner performing all the work myself.
NOTE:plcase be await that whilo homcowvcra who cmploy pazo=to do ma�co stntct on or repair work on a dwelling of
not Mort than Lbr-units in Which the homoowocr r=dca or oo the grounds appurtenant thm- o r.• oo(garcr'illy coasidcrcd to be
cmploytrs un'ia the woti s cempcmation Act(GL152,s1(5)),application by a homcowvcr for a licctise cc perm may evidcnee the
legal rtatus of an employer under the Workcet Compensation Act
I undertund thzt a copy of this ctatemeat may be forwarded to the Dcpertncni of Indiutriel Accadm&OfSoe of In �rsneo for the
ooverage vaificatioa and that failure to secttre covecngo under socfion 25A of MGL 152 can lmd to the incpos On of criminal pcnalLcs
ooaust=g of a fine of up to S1,500.00 mrNor imprisonment of tip to oa year and civil pcnaltics in the form of a stop Work Ord_—and a
fine of 5100.00 a day agz_i tt
For dcpsr—al—only
permit Number
Map t Lot#
i of Li crmittee e
Au
t - ..
� Y
SECTION-8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9�2ee t edl omg s r u on r cHIM, 0TOTt�... 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...... 0
rome� ne�xxempt><on
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/of 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 r:Terence to Chapter 152(Workers' Compensation) and Chapter 153 (Lability 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 res onsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning ws an to of sachusetts General Laws Annotated.
Homeowner Signat
SECTI6N 5 DESCRIPTIONi�.OF PROPOSED WORK(check all appIicable)
3't
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
iAccessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: X I Z 5-H09 j��A /9 /w �r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6 , If Neiti house air►d ddition to eAgtffig md—mhg;"'d6 !R1b e'JrJ#followih :
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. Proposed Square footage of new construction. Dimensions
I
e. Number of stories?
i
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 7a OWNER-AUTHORIZATION -'TO BE COMPLETED WHEN
OWNERS AGENT OR CONTR;aCTOrR APPLIES FOR BUILDING PERMIT l
I, as Owner of the subject property
hereby authorize, to act on
my behalf, in ali matters relative to work authorized by this building permit application.
Signature of Owner Date
1A, 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 Name
S' ure o ner/Ag Date
4
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 7 /
Setbacks Front
v �
Side L: R:''�d L: R:__
Rear
Building Height �a,1 7 A1.075-Off—� n
Bldg. Square Footage /7Q0/.
Open Space Footage %
t' (Lot area minus bldg&paved
parking)
#of Parking Spaces N !�
Fill:
volume&Location)/V
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW X
IF YES, date issued: ! (� X24
IF YES: Was the permit recorded at the Registryb `A7
NO DON'T KNOW
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of wat, or wetlands? NO X 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 X
IF YES, describe size, type and location:
D. Arre here any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
k
�
^ y
\
\
\
:
\
»y
^\
,
\
+.
% , � �
BP-2002.0780
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
BUILDING PERMIT
)780
Project TM 293
Est.Cost: $3000.Ou
Fee:$25.00 PERMISSION IS.HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 16552.80 Owner: BROWN MARE!);T&PATRICIA ANN
zoning:URB Applicant: BROWN MPREN T & PATRICIA ANN
A_T. 98 LAKE ST
Applicant Address: Phone: Insurance:
98 LAKE ST (4131, 586-0901 ()
FLORENCEMA01062 ISSUED ON:3121102 6 00:00
TO PERFORM THE FOLLOWING nTRE .Rl ECT 14 X 8 SHED
POST THIS CARD SO IT IS VISIBLE FRSTREET
In spector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footin sc
Rough- Rough: House # Foundation:
Drives ay Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
gh:
Oil: Insulation:
Smoke: Final:
MIT MAY BE REVOKED BY THE CITY O F NORTHAMPTON UPON VIOLATION OF
'RULES AND REGULATIONS.
V �1CV ; Si nature:
ei t No: Jate Paid: Check No: Amount:
ry/21/02 0:00:00 4861 $25.00
"**one(413) 587-1240,Fax: (413)587-1272
ssioner-Anthony 1'atillo
e !
i
�' i Northampton
n
i t5 Department
ain Street e
f1 ��` 5 2002 om 100
(� A� Northam ton, MA 01060 : .;
7.1 40 Fax 413.587.1272 Ppfl. to
w!
-K-p TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
r
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed 6y off ce
8 LA K-6 S1— Ma dot � un►#
�L- C) �� j D� Z_ Zone verlay Distr]ct
Elm St.District CB'District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�1J o� � o�b 6 Z M A�� 0 wog A-T 99 Z S rE
� game(Pri � Curr t Mailin A r ss:
_ (!VWv--'--Telephone
; Signature
2.2 Authorized Agent:
i
Name(Print) Current Mailing Address:
Signature Telephone
1 SECTION 3 - ESTIMATED CONST;2tJCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit ao licant
1. Building (a) Building Permit Fee �� Oj
2. Electrical (b) Estimated Total Cost of UO
Construction from 6 3j O
3. Plumbing M/ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5)
00� Check Number a
--� This Section For Official Use Only
Building Permit Number:_� �� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0780
APPLICANT/CONTACT PERSON BROWN MAREN T&PATRICIA ANN
ADDRESS/PHONE 98 LAKE ST (413)586-0901 Q
PROPERTY LOCATION 98 LAKE ST
MAP 17A PARCEL 248 001 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
Typeof Construction: ERECT 14 X 8 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessog 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
INFQ MATION 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 Co .ssion
Signature of Building Of i ial 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.