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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building S
Northampton, Mass. 01060
WORT{EW S COMPENSATION INSURANCE AFFIDAVTT
(li cens erJpermi tree)
with a principal place of business/residence at:
l I Wfl n''e 5 R,cPC r r3y 5 ,/'NA /q/05 (phone#) �ji V-!!l75
(strr city/sta&2:ip)
do hereby certify, under the pains and penalties of perjury, that:
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( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
'1 i atfon Date)
I: (Insurance Company) (Policy Number) (gyp
( ) 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/Policy Number) (Expiratioa Date)
if if
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml short if neo=sary to inohsdo information pertaining to all coat** s)
(� 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 homeowners who ernplay pasom to do maadea mce,constr t onor rcpairooaridcn to be
ing of
not more than three units in which the homeowner resides or on the groun6 gTurttnant thacto arc not gwKally
employers under the wmkces oomprms4oa Act(GL152,ss 1(5)�application by a homeowner for a license or permit may evidcnoe the
legal ctatua of an employer under the Worka'a C.ompamatioa AcL
I understand that a copy of this szaicmmt may be forwarded to tho Dcpwun at of Industrial Aoddm&Office of Irmruince for the
coverage verification and that failure to amrrc coverages under section 25A of MGL 152 can]cad to the imposition of criminal penddca
ooasistiug of a fine of up to S1,500.00 and(or impruo=xot of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against me.
gpermit t�uao only
Number
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Lot#
Signature o i ermittee e
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SECTION ECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:— 7- '146AIr 5 C.,/Y d
License Number
2-Z 2Z1J- �L
Address Expiration bate
4:9� !� �� �5 V- 7.5-6
Signature Telephone
20111%1 MIKIIN Not Applicable ❑
Company Name Registration Number
-7
IL--Z2�,a 2—
Address Expiration'Date
.12 /t e571P 5- 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...... ❑
N
A
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
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5fCTIQN 5 DESCRIPTION QF PROPQSED WORK(check all applicable}
New House ❑ Addition 93/ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
i
Brief Description of Proposed Work:/�l�/5 1,K&G7 #G�V X 119 d.(/¢ S t1/lii 134-r�l?D A( A'04-I'leAl
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative o Renovating unfinished basement Yes �'' No
Plans Attached Roll ❑ - Sheet-K
a. Use of building : One Family C,-"" Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?0
d. Proposed Square footage of new construction. 5). 75 5r Dimensions
e. Number of stories?
f. Method of heating? G4,F�- WQ k1_ IrA471- Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. s--rm l i 0i. Mascheck Energy Compliance form attached?
s
h. Type of construction JrWVP F/LAA&
i. Is construction within 100 ft. of wetlands? Yes _LZINo. Is construction within 100 yr. floodplain Yes ✓�N0
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? L,-' Yes No .
I. Septic Tank City Sewer Private well City water Supply_il�
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR'CONTRACTOR APPLIES I:OR BUILDING PERMIT
I, CDlrt/A2o) � s as Owner of the subject property
hereby authorize to act on
my behalf in all matters relative ttoo work authorized by this building permit application.
'
Signature of Owner Dafe
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.
LR in da !Z T
Print Name
A• 1 4/0
Signature of Owner/Agent/V Date"
^ .
. .
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
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved 71
of Parking Spaces
(volume&Location)
A. Has Special Porn1it/Vahanoo/FindinQ ever been issued for/on the site?
N0 DON'T KNOW YES _________
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO DON'T KNOW �� YES _______
IF YES: enter Book PaQa and/or Docurnont #
B. Does the site contain a brook, body of water orwetlands? NO DON'T KNOW
YES ______
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tmbe obtained Obtained , Dote Issued:
C. Do any signs exist on the property? YES NO
|F YES, describe size, type and location:
D. ere any proposed changes to or additions of signs intended for the property?YES
Nov
\F YES, describe size, type and location:
ii
City of Northa pt:-%I—
lNINSPE�OF BUILDBuildin De ar � ORTHAWTPU
MAO
212 Main Stree
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'-SITE INFORMATION
"'This" c � A
1.1 Property Address:
qq y,
j '
Elm St Distri`q"
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SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/_ A lr ✓ ,�',Cy:�✓".y<�=
Name(Print) Current M�iID Address:
Telephone
Signature
2.2 Authorized Agent:
4A"y J yiGwrSC-H
Name(Print) �I Current Mailing Address:
4j L j/3 ' J �j y Y-7,5-0 Signature �� Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building �f. �i�® (a) Building Permit Fee r �
2. Electrical (,O 6 ,-- (b) Estimated Total Oust of
o Construction from Q6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) d °�° Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0262
APPLICANT/CONTACT PERSON Larry Yentsch
ADDRESS/PHONE P O BOX 120 (413)584-4750
PROPERTY LOCATION 26 SUMNER AVE
MAP 17C PARCEL 171 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 10111 IF6_0
Tvueof Construction: CONSTRUCT 5'6"X 10'6" 1 STORY BATHROOM ADDITION -
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure -
Building Plans Included•
Owner/Statement or License 048666
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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
Signature of Buildin 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.
26 SUMNER AVE BP-2001-0262
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 171 CITY OF NORTHAMPTON
Lot -001
Permit: Buildi g
Category:ADDITION..
BUILDING PERMIT
Permit# BP-2001-0262
Project# JS-2001-0440
Est.Cost:$8100.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Cont.Class: Contractor: License;
Use Crroup: Larry Yentsch 048§66
Lot Size(sq.1): 11020.68 Owner: ADKINS EDWARD T&ELIZABE'I`H S
zoning:URB Applicant: Larry Yentsch
AT: 26 SUMNER AVE
Applicant Address: Phone: Insurance:
P O BOX 120 (413) 584-4754
LEEDSMA01053 ISSUED OAT 9115100 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 5'6" X 10'6" IN
PIN
ADDITION c �,,
POST THIS CARD SO IT IS VISIBLE FROM THE STREET �'po
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Bu _0 cn ��C E
co m 3
Underground: Service: Meter 0 0-
Footings:
h
Roug 'y p RW6 Rough: it pl# plof
# Foundation:
Z o O
Final: /a G /Aa, Final: ('fi"�/ "'r Cl) Z co
® ( Rough frame: M Q-
61,
- v� o O
o C)
Gas Fire Department Fireplace/Chin Z
r m
cD
Rough: Oil: Insulation:
v rn 0
r �
Final: Smoke: Final: 0 K O
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON-vwLz� -ANY OF ITS RULES
_ AND REGULATIONS.
Certificate of O cu n R
si n turr.
Fee Tyne: Receipt No: Date Paid: Check No: Amount:
Building 9/15/00 0:00:00 1081 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo