The URL can be used to link to this page

17C-284 (5) y 4-�1�PT0 0 10- �O e B . � �x� 1a� �i7Z#�jbillt�.T�IITt - � e �aasarE(nsttls' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licensee/pcim tree) with a principal place of business/residence at: (phone#) (streeUci ty/statr/a 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: (Insurance Company) (Policy Number) (Expiration Date) ( ) 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) (Expim6on Date) ,, (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) (a[Iach additioail shod if neocusry to'include iafvcmiIIon pertni�to all ooatrncton) ( ) 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 awztn that whilo homcov n-n who employ paiom to do==tcaancc,con try oc or mpau work on a dwelling of not Mora than throe units in which the hombowncr resides or on the grounds apprutcnarrl thm io arc not gaxtally oomidard to be employers under the work r,ration Act(GL152,s3 1(5)),application by n homcowar for a license or permit may evidence the ]cgst ctictus of an employs undertho Workeez C.ompamaiioa Act I uadetatand that a copy of this ctatemmi may bo forwarded to the Dcpactmca2 of Dial Accidmt�Offioo of Inxrrwoe for the coverage vcnficatioa and that fadme to seeuro covenrgo under section 25A of MGL 152 can kid to the imposition of criminal penalties eoasistirrg of a fine of up to S1,SOOAO and/or imprisoumcs3 of tip to one year and civil penalties in the form of it Stop Work order and a film of 5100.00 a day against mc. For dcpartm use Daly Permit Number /6 0 1„�p�{ Lot# .. Signature ofLiccn-sce/Permittee SEC1IONr "' �CONSTRiUCTION SEF2VICES " 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone m 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...... ❑ 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 �i`GION S' D'ESC P OSD N ORPWOR a1 a hcabl P' T 4 W e 4Ld #3 +� 3. 5^M✓fia Y.. L3 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other' Brief Description of Proposed Work: `eplat2 Alteration of existing bedroom Yes_ No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ ' tltl t":o o thn t usin" c�oYn"�" e. rdfl6017 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 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; TOBECOMF'LETEf) WHEN 01 'NERS AGENT 0RKCONTRACTOR AC'PLIES�FOW..” UILDING PERMIT 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. Signature of Owner Date Py 4 j/Q ®� as Owner/Authorized Agent hereby declare lliait 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. Pam.�cj L CA 1-U eP� Print me Signature of Owner/Agent Da 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 + Z c✓�, Frontage Z Setbacks Front 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 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 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: City of Northampton i g Department Main Street oom 100 ort pton, MA 01060 APR Une 4 1 240 Fax 413-587-1272 A40, ;0 ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ` f �seC i4 t ompfe" Of C H g Maps p 3 l OT?a �'p �'! a f d '`� Zorie � lay DIstr� ((�� Elm St'District ;,"C113-,61 t SECTION 2!- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t- 1 5Gr((4 c)�3-S Z 4 Cr C T ar c, Name Print) Curre-t--U-iljng dress: � Telephone Sig ture 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION.3!- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �t ( �C) O (a) Building Permit Fee 2. Electrical �f�' `' (b) Estimated Total Cost of Construction from 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 Buildi.ng�Pe,rmit Number: Date sIssued: Signature: Building Commissioner/Inspector of Buildings Date �-- File#BP-2002-0882 APPLICANT/CONTACT PERSON ROSS PRISCILLA M ADDRESS/PHONE 28 LILLY ST PROPERTY LOCATION 28 LILLY ST MAP 17C PARCEL 284 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out vqa Fee Paid Typeof Construction: REPLACE DECKING ON PORCH New Construction Non Structural interior renovations Addition to Existing Accesso1y 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 INFO ATION 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 Commission W,&z -,� -:q1'A1?- !:e-17. 0 2 Signature of Buildin 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. 8 LILLY ST BP-2002.0882 GIS#: COMMONWEALTH OF MASSACHUSETTS - a :Block: 17C-284 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2002.0882 Project# JS-2002-1456 Est.Cost: $25.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): 10890.00 Owner: ROSS PRISCILLA M Zoning.URB Applicant. ROSS PRISCILLA M AT. 28 LILLY ST Applicant Address: Phone: Insurance: 28 LILLY ST FLORENCEMA01062 ISSUED ON. TO PERFORM THE FOLLOWING WORK.-REPLACE DECKING ON PORCH 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 4/17/02 0:00:00 1029 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo