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17D-019 (9) r- ,�►. � I i I i i i I i i i I w oQ-PTO e $ 6 �asssscknsetts' M of Xart4aiuvtou vt DEPARTMENT OF BUILDDZG INSPECTIONS 212 Main Street a Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSA'T'ION INSURANCE AFFIDAVIT with a principal place of business/residence at: Z le Q, t,)La 4, 0, (phone city/Aatdzip) do hereby certify, under the pains and penalties of pe4ury, that: G ( ) 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: A1r Z WC-g057?4 (Name of Contractor) V (Insurance Company/Policy Number) (Expiration Date) t7, (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 ad&doml sheet if noecsary to include infamahoa pertaining to ell ooetradors) 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 employ pasom to do mainta�omshvdim or repair work on a dwelling of not more than three units in which the homeowner resides or on the grmnd,appurtenant therdo art cot generally oontidertd to be employes under the workerAs oompcasatioa Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal status of an employer under the Wo&aeg Compensation Act. I underYtaad that a.copy of this cut=aad may be forwarded to the Departaxnt of Industrial Accideo&Office of Insurance for the coverage verification and that failure to accrue coverago under section 25A of MOL 152 can lead to the imposition of criminal pea&Wes eoasisting of a tine of up to S1,500.00 and/or imprisoamaod of up to one year and civil pcnm,6c%in the form of a Stop Work order and a fine of 5100.00 a day against me. For dgmtme use oaty Permit Number Mao Lot# st of Licensee/Permittee i � ^� � i i i i I i i S CTION'8—COKTIRUCTIOR SERVICES 1 Licensed Construction Supervisor: n{ Not�gApplicable ❑ Name of License Holder: �Jt'lt°�')� K 55 [Jt- S License Number a 1P n�� �e - A lta . d Dq q)adDZ Addr s Expiration bate Signa q a Telephone Not Applicable ❑ :rDc kc)tLD S 1 --2;D 3q:7 Company Name Registration Number Address Qf Expiration Date Telephone of —711J ;ECTIUN ,bW W6RXERS' C4MPENSATIQN 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. igned 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 i 5 pro�ec, ►5 a�o�a✓�U� an i� jOb , Apt o► s ; lm�. 1�s r r�fa f �►e e are v�e-ed �l{ aU' a �4f l Ua i '(2 cox �� w Ube alt i e I 1�► Ls S Aftesc I% S o-K- S 1, i � i 1 1A IBC r� , f�C Cc�cc��- Vic, r�e�eSsaf Seaw.`es 5 c�1;1� bE �aC W � � 5 � C�0STALI.Ejb 3y L4$MY JUSS S�a,►�Cess Gvrt1"C-2S� Fat 04\," ftc� Oaf i i� Ike iJ©2-�14►`�Q7�� L �F��l- 0� CWR�^ M � R New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work:5-ne) PoA tq AxF OVE1,11 aS pit c swr S v �S rr�V t ea Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached NarrativeX4!5ee Renovating unfinished basement Y Se, No Plans Attached Roll ❑. Shee o r 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? 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 SEC7`IOM,Tar-O MNER AUTHORIZATION.-T4 B1:,OOMPLETEp WHEN tr'WN ASiAGENT"Q� C NTRACTOR APPL,IE'S FO BUI�N�ING 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. gnature of Owner Date l �YY1C5 �� PSS -T%ft &-)I LbE-7gS' 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. igned under the pains and penalties of perjury. fh S Pr t NWN Signatu caner/Agent Date i N w 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 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 X 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: i � 1 i i I i R E C E Q Vitgof hampton Buildi partment MAR 2 9 200f 1 I OOeet Northa pto , MA 01060 DEPT i4�N41113EBfNS124 Fax 413-587-1272 NO THAMPTON,MA 010 0 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE iNlrORMATION 1.1 Property Address: N a ' ' 'S Y I MR l�l STe-Au'3 A v C �� bbe610E , mss S sit y t „ s� # rlct AV S"ECTIf1N PROPEOY OWNERSHIP/AUTHdRIZED AGENT 2.1 Owner of Record: ff S Ft2Pw0 tq UE Name(Print) Current Mailing Address: Telephone Sign re Authorized Agent: ,�►�, `�. ►ass t7B�4 �-�urc.�S �x C�Co , wl��.el� rnR. OrD�3 Name( t) Current Mailing ddress: a47-1(6� Signature Telephone ES:['jMAT-EDfbbNSTRUCTION, COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 4 CIS M (a)"Building Permit Fee J . 2. Electrical (b) Wimp"ated 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„Nurriber . .This Section Fur Official Use Only Building Permit Numbe Date Issued: B”uiloing,CgrorYtissioner/Inspector of,Buildings Date File#BP-2001-0765 APPLICANT/CONTACT PERSON JDR BUILDERS ADDRESS/PHONE 236 HAYDENVILLE RD (413)665-7587 PROPERTY LOCATION 117 STRAW AVE MAP 17D PARCEL 019 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid L5;2 7 Tyueof Construction: STRIP PLY&SHINGLE PORCH ROOF REPAIR ROOF OVER BULKHEAD& INSTALL GUTTERS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074105 3 se s of Plans/Plot Plan T/Approved LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: 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 Co ion Permit from CB Architect Committee 6 d Signature of Building Of 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. 117 STRAW AVE BP-2001-0765 CIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-019 CITY OF NORTHAMPTON Lot:-001 Permit: Buildinq Category:roofing BUILDING PERMIT Permit# BP-2001-0765 Project# JS-2001-1433 Est.Cost: $4515.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JDR BUILDERS 074105 Lot Size(sq. ft.): 19819.80 Owner: RUSSELL JAMES E&PATRICIA A Zoning.URB Applicant: JDR BUILDERS AT: 117 STRAW AVE Applicant Address: Phone: Insurance: 236 HAYDENVILLE RD (413) 665-7587 WHATELYMA01093-0066 ISSUED ON:4141010:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE PORCH ROOF, REPAIR ROOF OVER BULKHEAD & INSTALL GUTTERS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 4/4/010:00:00 527 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 117 STRAW AVE BP-2001-0765 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-019 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofm BUILDING PERMIT Permit# BP-2001-0765 Project# JS-2001-1433 Est.Cost: $4515.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JDR BUILDERS 074105 Lot Size(ss . fl.): 19819.80 Owner: RUSSELL JAMES E&PATRICIA A Zoning. URB Applicant: JDR BUiLDERS AT. 117 STRAW AVE Applicant Address: Phone: Insurance: 236 HAYDENVILLE RD (413) 665-7587 WHATELYMA01093-0066 ISSUED ON:414101 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE PORCH ROOF, REPAIR ROOF OVER BULKHEAD & INSTALL GUTTERS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 0�' THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/4/010:00:00 527 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo