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DEPT OF BUILDING INSPECTIONS
NORIPAMPTON,_MA_010b0
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(liccuserJpermittee)
with a principal place of business/residence at:
(phone#)
(street/city/statdzip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the follollving worker's compensation coverage for my
employees worlang on this job:
ansuranoc Company) (Policy Number) (Expiration Date) F
( ) 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 Comparry/Policy Nwnbcr) (Expiration Date)
f.
(Name of Contractor) Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insu ancn-Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneccs: to inch>de kd6rnstion pertniuing to all O'ad rs)
( ) 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 whim homoownCr3 who employ pazom to do r Er r„ru c conshuction or repair worst on a dwelling of
not moo than three units in which the bomoo-, c reside or oo the grounds appurtenant iha-do arc not gencralty coendcrcd to be
carploycr s under the Wm ct`s compcusatioa Act(GL152,m 1(5)),application by a homeowner for a license cc permit may evidence the
legs,status of an employer under the W"keez Compeosation Act
I undoratand that a copy of this vw4mcat may be forwarded to the Dcpa umod of T-du d Amid—&Qffioo of ln3t co for the
coverage vcrMcatioa and that failure to v==covnugo under section 25A of MOL 152 can lead to the imposition of criminal Penalties
oomisting of a fine of up to S1,500.00 and/or iinprisoarocnt of up to one year and civil pcmltics in the form of a Stop W orlt order and a
frog of S 100.00 a day against mc.
For dgrart=a use only
Permit Number
p,4 Lot#
; :G. Signature of Li Permittee e
%
SECT ��v =1QgN 5ERVi,rs
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re d veme r c r, EMr 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 'th 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 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 .D ., 'C P3 :� 01< PR POSED�t3 cfieckal 'a licabfe
Q 0V
New House ❑ Addition ❑ Replacement Windows Alteration(s) O Roofing ❑
j Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other[ ] Aµ
4�
Brief Description of Proposed Work:
Alteration of existing bedroom Yes___ZNo Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
j Plans Attached Roll ❑- Sheet
: IJb
saIfN wh"or a doAdito� t e
a. Use of building : One Family Two Family Other ht;
+
ACC"40 ry !"V.
b. Number of rooms ink chit: _ Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? ekr5� v-
f. Method of heating? 96LS i a-1<1 Fireplaces or Woodstoves Q Number of each 0
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction WOOD 1F"t4%Q.
i. Is construction within 100 ft. of wetlands? Yes _7C No. Is construction within 100 yr. floodplain Yes No
rt.X.i etc n5
j. Depth of basement or cellar floor below finished grade cy-aw
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer_ A Private well City water Supply A
SECTION 7a=.01NNER,AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CQNTRACTOR,,APPLIES,FOR BUILDING PERMIT
Awoy� r
5 � �- 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.
el
ZJ
Signature of ner Date
as Owner/Authorized Agent
hereby declare tha he 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
Signature of Ow er/Agent Date 10 '-/7` Df
i-
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION -)It Vie- w rlet- G-I-ef�
1N':;' z 11. ST IN61-
Existing Proposed Required by Zoning 6T ow �T-V�SZ
This column to be filled in by
Building Department
6i6° us
Lot Size y Q 6- �Sfr��a3
Frontage
Setbacks Front odd ,c tw
Side L:o�`� R: `cy' L: R:
Rear
Building Height l J �. \k it
Bldg.Square Footage 1/d X % z I C ���
?r1T,4- S R
Open Space Footage V % 2-�L S'�' it
(Lot area minus bldg&paved cc (}-� + a Ptp,
parking) O :a
#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 V
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:
E E u y rthampton
Builc Mepartment
OCT 18 2001 21 in Street
0 100.
41Q�thallrnptc n, MA 01060
DEN ftE RN1 5?E�:T1Q�S,_12 0 Fax 413.587.1272 a
t�iA� 1�b1t6{1'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
Th�s se to lie completed ti office :
1.1 Property Address:
evi °t ` Y
Zone ., t Over[a Des#rtc 1
/n it, 69106'
„Elm St istr c'ti GCB Districtsi .r
._ .�.....,w. .....
SECTIPI`+2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print Current Mailing Ad ess:
�lL�/ ( lLtt rLaU7� Telephone
ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature v Telephone
SECTION.3 - ESTIMATED CONSTRUCTION-COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �C� (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing - Building Permit Fee
4. Mechanical (HVAC) 7,00
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number
This Section For Official;-Use;Only
EulJdmg Perini#,Number.. Date Issued:
3 ..
Signature i ',
Buildin Commissioner%Inspector:of B. Il,'in s
B g D'ate
:
File#BP-2002-0415
APPLICANT/CONTACT PERSON CHRISTENSON MARY E
ADDRESS/PHONE 29 KEYES ST (413)582-0464 Q
PROPERTY LOCATION 29 KEYES ST
MAP 17C PARCEL 147 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ADD NEW BATH &KITCHEN FOR ACCESSORY APARTMENT WITHIN EXISTING
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
INFATION PRESENTED:
✓✓Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 Comm' ion
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.
• R
BP-2002-0415
GIs#: COMMONWEALTH OF MASSACHUSETTS
.� 1c: 17c=1a7... CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: ACCESSORY APARTMENT BUILDING PERMIT
Permit# BP-2002-0415
Project# JS-2002-0628
Est. Cost: $8550.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 10367.28 Owner: CHRISTENSON MARY E
Zoning: URB Applicant. CHRISTENSON MARY E
AT. 29 KEYES ST
Applicant Address: Phone: Insurance:
29 KEYES ST (413) 582-0464 Q
FLORENCEMA01062 ISSUED ON.•10 125/01 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD NEW BATH & KITCHEN FOR ACCESSORY
APARTMENT WITHIN EXISTING
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 10/25/010:00:00 4624 $50.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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city ►NS E TION LABEL
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Gas Inspeo°r
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29 KEYES ST BP-2002-0415
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 147 CITY OF NORTHAMPTON
Lot: -001
Permit: Build Dg
Category: ACCESSORY APARTMENT BUILDING PERMIT
Permit# BP-2002-0415
Protect# JS-2002-0628
Est. Cost: $8550.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 10367.28 Owner: CliRISTENSON MARK'E
Zoning: URB Applicant: CHRISTENSON MARY E
AT. 29 KEYES ST
Applicant Address: Phone: Insurance:
29 KEYES ST (413) 582-0464 (�
FLORENCEMA01062 ISSUED ON.10/25/01 0:00:00
TOPERFORM THE FOLLOWING WORKADD NEW BATH & KITCHEN FOR ACCESSORY
APARTMENT WITHIN EXISTING
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: �: Service: = '' < ; fl' Meter:
Footings:
Rough: f '/flel Rough: (�;_s?"',House# Foundation:
Driveway Final:
Final; wGti� .;'e� Final 13 OZ
eve Rough Frame: k
Gas: ������`�` Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: ( O a
Finalz*(")O*f Smoke: Final: O/C 3-/y-e a
THIS PERMIT MAY BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLAT ON OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/25/010:00:00 4624 $50.00
212 Main Street, Phone(413) 587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo