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DI-PA TMEN7 OF BUILDrT,,G 1NSPE�1'10NS = -'
212 S.-�zct Municipal Built:ing ��
Northanlpten, Vats. 010U) "
`N'ORIC,R'S COOMPENSSATION INSURANCE AFIMAVIT
c IS (17c�vserJPerm•'��)
/37 f� OGir✓�a.--� /�o� Q. /1�� � �--(1�hone } 59Y-72do
(Street/ci t7'/sta?.el2�p)
do hereby certify, under the pains and penaltes of pe-T ry, that:
(kj"I am an employer providing the followng worker's compensation coverage for my
employees wor'r�ng on tliis job:
( ce ? .Su/"-K —c c— K)6 Iq 30 2 G ?d 3 �i to �o y
HxrL Lti. L L )
a so'e prourietor, general con actor c)r hoalt-3"!er �CU`C one) aria lave h led
the contractors Lsted below who have the worker's coe.aensa ion policies:
CN,= of Contractor) 0 s=ance Compan--•
CName of Cont.6c,cr) (Insuran�;., Compaiyi-i oky Number} (E� ration Date)
(Name of Co=2cloi) C",
o;Contractor) aan; cc Comp,_-1/Policy Nt:mc�_r) (E pi zuon Da_-
(atlas ad';;Dail r?xct if no�v.r�tc is ludr iLfxmi.'ieo patni�ing u all oa2nCo:�)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner perforrlung all the work inyseff.
.NOTIl,c._ bca•� a 'ilcYc. u'>ra�t'xc-lcry}cmudcx_ a _ �ao:rra tic.iC-E of
voC axYt L'�.::v.�cc u..r�is wasi�c•_+Y b^-a�r'ancr m;d.�or oc
cti lo}cs i�:a OV:wxi r>a cc--.;-:z�cn Act(Gi 152 a i(5)} a{pti by►Lzc=wDa fc.s ccix or;xs racy e�i:axx tSc
leSl rta:iu of an crployer under rho Wo&ceg Compernafion Acc
I undr ztand tluf a copy of this ruL=cat may bo farvmrdad to the DqS tnm,cf lnAnf is Aocid,s'OIL,of I_for the
co��c.-�£c vciifiG:ioo a�flat Giltn-c w E�:rc cuvcrn�tuk'lcr section 2SA.a�1,lGL 152 cap tad to Lhc ir:rvt:lio:.of m�ril pcaalt:a
n�s::r.2.o£a L•:x o£t:;to S 1.500.00 en:':x im-,-..^iser•naY o£up to cx�-�.�t-a�a�i'.pQ.r!tia it L`.�fcxm cf r.5�,V.'�Order x�.i a � •
fo(S:CU.CCI��y■
Fcr dyad;�-.a:us^mly
1 ^,tom
.Si Cnatuic Of L.ICC;.15C^.,�}�[rlllltt[^
SUMON 8 - Cjt4S'I kiCTION SERVICES
f�j Licensed Cons t- t,:)t kpplicable ❑
L le,C X7 -,t_ S 3
I A-7
1 License Number
Sig EK,,-, ation Date
at.re I e e P!,
.9. -i-aistered home imp to�en'_Int Contractor::..,_. Not Applicable ❑
(f A,5,f XA , ,-I', s:'-A"--C V- / 3 Z/ '7 Z:
L_y ?rnn _Nc Registration Number
p_
3 7 - /-�- f>a .�d.� �Ca /Z/5 �o y
Ac Expiration Date
Telephone 58y 77
_O 0
_-TION 10- )i%OPKIERS' CO',.PENISATION !N51_'PANCE .,,MDAVIT (M.G.L. c. 152, § 25C(
Workers Compensation insui-F-ce affidavit must be co- -D'eted and submitted with this application. Failure to provide this affidavit
Will result in the denial of the issuance of the building permit.
'ttac'h d Ye: No...... E.
1 . Home Ov,-ner Exeillpfi(►il
The ci.;-,-.:nt exempt:(:. imr hoii.cownes" %Nas extended to include ONN ner-occupicd Dwellinas ofone(1) or two(2)families
a-
.1d to alIoNv such hon.comier to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CNIR 780, Sixth Edition Section 108.3.5.1.
Definition of Homems ner: 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 fa:nil'. dwcllirig,attached or detached structures accessory to such use and/or farm
structures. A person N%ho constructs more than one home in a two-year period shall not be considered a homeowner.
such "hnnwc).":ITT" shall sus:-,it to the Bi7ill:no Official,on a form acceptable to the Building Official,that he/she shall 1,(
-m';!)Ic ff , :01 sl;(11 N� 11—Irint-, widt r the buildin� permit.
AS Ct coil'trm:tio " Silpef.N i"o, i)ur presence 01"the job site \Nil] be required from time to time,during and upon
o of :'t' to, 'M ICI pc I J.
Also I be advised that \N ith 1-cfe,cricc to Chl,ptci 152(Workers'Compensation) Li:I Chapter 153 (Liability of Employers to
you ml be liable fc- irii"--ic n(" (�flhe Massachusetts General Lav, .Annotated, for person(s)
u �i� 1j;Is
h'c tin, cI 5 certi_-s and assumes responsibility for compliance with the State Building Code,City of
itl aT)J 1 o,,d Laws ailG Sj51e of rMlassz,,chusens Ccer�l Laws Annotated.
*
ddi,icin 0 Replacement Windows rAltera,,'on(s) lk-� koofing 0
Or Doors 0
Acccs!,ory D Di'rnolitiDrD New Signs Decks Siding Other
Br�c- Description of Proposed Work:
Alteraticin, of existing bedroom—Yes 14 No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
6a if New house afid'or'ziddition to-exi§fing'hbusiniZ., complete the follqwln
a Use of building : One Family Two Family Othe,
b. NL�mber of rooms in each 4amily urit. Number Bathrooms—
c Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Numbe-of stories?
f. Metho," of heating? Fireplaces or Woodstoves Number of each
E Energy Conservation Compliance. Mascheck, Energy Cornpl�ance form attached?
h. Type cf construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction wi,hin 100 yr. floodplain_Yes
j. Depth of basement or cellar floor below finished grade
I, VVil; rjuil--;ng conform to the Building and Zoning regu!atioris� Ye No .
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
rny behalf, in all maners relative to woOK aut-iof ized by this Luildlr�e pr/omit
hereby declare that the statements and information on the foregoing application are true and accurate, to the b,'st of my
V,,iowledge and belief.
Sii�necl under the pains and penalties of perjury
Print Ni-Tle
----
i r
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 Sizo
Frontage
Setbacks Front
.: L: R: L: R:
Rear
huiidin He'011
Bldg. Square Footage °r
0,�cn Space Footage %
;Le;area minus bldg t paved
a king)
i
0 of Parkin- Spaces
I Fi l:
(v,_duTr &Lr•caticn) I
A. H,--s 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 Z 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
----------- ---- v.Department us-
y of N`lorthan, pton �tctus of Permif.==
6uil ;in7 Department
212 Blain Street S,ewe / er, y b
Room 100 Vale-/Wei' A ad'abilrty
Northampton, NIA 01060 Two Sets 6f Si"rycturGi '
phone 413 587.1240 Fax 413-587.1272 Rot. si!�% P a- -�— 'I.
Other S' eci
APPLICATION. TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWON-LY-.D-Yy'. r.LING
AN r
I E-ECTION 1 - SITE INFORI,'iATION
N This section !o be completed by office
1.1 Prope�t __Address:
Ca ke Sfrce Map /7 Lot d3 U Unit
Zone Overlay District_-
Elm St. District_ CB District
SECT TION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Vie/ s s /<q e,/2
Current Mailing Address:
SS _ Telepl-one G Q G
Sig ,aturt ✓p 5 Q 2
2_2 Authorized A ent:
Na^ c (i . nt- Current 4r1ailing Address:
X
Si€€--tu;. ---- — Telephone
SECTION 3 - ESTIr,".ATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. 5uildir g (a) Building Permit Fee
$oo , ao
2. Electric?! (b) Estimated Total Cost of
« ` { O d . O U Construction from (6)
3 Plumbing Z .150 0 . Building Permit Fee
a �
4. Mechanical (HVAC)
5. f=ire Protection
6 Total = (1 + 2 + 3 + 4 + 5) /rj Oz7, a a Check Number
This Section For Official Use Only
Building Permit Number: _ F D�telssued:
Signature: _ -- ----_-------�
Building Commissioner/Inspector of Buildings — Date
File#BP-2003-0886
APPLICANT/CONTACT PERSON CASE HANDYMAN SERVICES INK BLACK,INC
ADDRESS/PHONE 137 DAMON RD SUITE C1 (413)584-7700
PROPERTY LOCATION 99 LAKE ST
MAP 17A PARCEL 230 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid _
Typeof Construction: RENOVATE 2ND FLR BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure -
Building Plans Included• -
Owner/Statement or License 073454
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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.
99 Lti:__. .: BP-2003-0886
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 17A-230 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0886
Project# JS-2003-1428
Est. Cost: $15800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CASE HANDYMAN SERVICES INK BLACK, INC 073454
Lot Size(sq. ft.): 8668.44 Owner: KUENY TUCKER&MELISSA S
Zonin :gURB Applicant: CASE HANDYMAN SERVICES INK BLACK, INC
A T. 00 L ir S7
"AA.
- .i .a'r .:7i
Applicant Address: Phone: Insurance:
137 DAMON RD SUITE C1 (413) 584-7700
Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:4117103 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE 2ND FLR BATH
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: 6`-'Mor 3 House# Foundation:
( /'L DAti� Driveway Final:
Final: q Final://3 f�0!/7
Rough Frame:Q -7-0,5
Gas: Fire Department Fireplace/Chimney:
Rough: Oil Insulation: 0I,
Final:
Smoke: - Final: Q K �'°?q' 03 '� '✓
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate Of Occupanc
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/17/03 0:00:00 795 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
NNNEnw-