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17A-230 (3) i i JET k. iv I h t t 2 � P 1 _ t , i " i { j k 4 i � { i i°�• h t 4 3 r a • -(1{AMP�. - Z'04 O 9 g �x X7 NDrfijaill1toIl Z � B �:isxchtrsrtta' e DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE { j AVTT --- ------- (licensee/permittee) with a principal place of business/residence at: to _'-Fi u i'11 A C O b�.Z- (phone#) �f! T `� `�� 0�' (street/ci ty/state/zs p) do hereby certify, under the pains and penalties of perjury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Iasi=ici� Company) (Policy Number) (Expiration Date) ( aIIl a sole proprietor, general contractor or homeowne circle one) and have hired the contractors Listed below who have the following worker's compensation policies: �JC 109 00 427.5- Tedd o Roc>& Tom. ('NA -C„ h��► �= e� Q 'c c me of Contractor) (Insurance Company/Policy Number) (Expirnuca ate) (Name of Contractor) -- (Insurance Company/Policy Number)-- (Expiration Date) (Name of Coati-actc,r) (Insurance Compan-y/Policy Number}--- (Expi motion Date) (Name of Contractor) (Insmaace Company/Poli(7,;•Number) (Expiration Date) (arIach addi6carl s�cct if ntcrsury to iacdtsdc information pertainutg to all ocatrn. or3) O I am a sole proprietor and have no one wod ng for me. ( ) I am a home owner performing all the work myself. NOTE:plcasc be a?v-r that while homcorvn,=who ctmploy persons to do mama co jf u goo or repair work on a(!NN--tag of not mocc than throe units in which the homeoumcr resides or oa the grounds appurtenant thereto arc not generally coasidacd to be eazployer3 undo the woritct's compc=satica Act(GL152,"1(5)),application by a homeowncr for a license or permd may-idmoe the legal;tabu of an employee under the Worket'a Compoosatiou Act. I UOdCrIlAnd that a copy of this rtatcmcat may bo forwarded to tho Dc�of Indrutrial Aoa&d &Offioo of Irrurs000 for the coverage va ficatioc and that failure to secure coverage under section 25A of MOL 152 can lead to the imposi6ou of criminal pcuaWCs ooausung of a fine of up to S1,500.00 and/or imprisoumcrst of up to ono year and civil pcnaltia in the form of a Stop Work OrdG and a fuze of 5100.00 a day against toc. For departmental rite only Pcrmit Number D-i � I b� Map' Lot# S -dum of Li e e �.. : SECTION-8-,,CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : f ' ' - License Number � 4:r Address Expiration Date Signature pone J � .R r -re " e x n e fl , ed�;> ,ii , 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 oJAhe building permit. Signed Affidavit Attached Yes....... No...... ❑ pwl X1.1:;.�H�omOw�nex� empt><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/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 1512(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. Homeowner Signature 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 ALL )� 2OC' tN 0 Frontage Setbacks Front 'S 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 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: ente.r Book Page _._ and/or Document # B. Does the site contain a brook, body of water or wetlands? NO _ 2(, 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 A IF YES, describe size, type and location: r SECTION 5 DESCRIPTIONOF PROPOSED WORK(check a'II applicable) 3 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New igns [ ] Decks [ ] Siding [ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a Ifi:New�ho" se,�" t,o dditi.on,zto�eclstirrg�.h:ousing,�:complete:�the�foll. "wing_ 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 I g. Energy Conservation Compliance. _ Mascheck Energy Compliance form attached? i n. 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`ACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject properfy 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 knowledge and belief. Signed under the pains and penalties of perjury. Print Name _— -- CA U L Signature f Owne Agent Date p-e# rthampton t department n t; In Street e APR g 'g i m 100 fgnn,, rtN'i on, MA 01060 et L, <�an�-41�-5 7.1 40 Fax 413-587-1272 PIo Stt�f APPLICATION TO CONSTRU , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION1 -SITE INFORMATION 1.1 Property Address: This section>to be completed by off ce Lot w ni © done a Overlay District " or et C C� 1 'f C t_I tC C� L Elm St District CB Districts SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT y 2.1 Owner of Record: rA Name(Print) . J Current Mailing Address: Telephone Signature �� 61< x(107 �' � Vo At )11a eo 2.2 Authorized Agent: Sri cy = - -------- - Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dol';ars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction,frorr 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number _ This Section For Official Use Only Building Permit Number: Date issued: Signature: Building Commissioner%Inspector of Buildings Date J File#BP-2002-0859 APPLICANT/CONTACT PERSON KUENY TUCKER&MELISSA S ADDRESS/PHONE 99 LAKE ST (413)585-9025 Q 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 Buildiniz Permit Filled out Fee Paid Typeof Construction: INSTALL 4'ABOVE GROUND 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 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 Pe iit from Elm Street CorpMssion r 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 LAKE ST BP-2002-0859 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-230 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Above ground pool BUILDING PERMIT Permit# BP-2002-0859 Project# JS-2002-1429 Est.Cost: $1000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sq. ft.): 8668.44 Owner: KUENY TUCKER&MELISSA S Zoning. URB Applicant: KUENY TUCKER & MELISSA S AT. 99 LAKE ST Applicant Address: Phone: Insurance: 99 LAKE ST (413) 585-9025 0 FLORENCEMA01062 ISSUED ON:4111102 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 24' ABOVE GROUND POOL 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 4/11/02 0:00:00 371 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo