18C-098 (2) a - ( 11-.vr p�,
� o •,-I �� (rib of Northampton 1
• A� 45 f 1 —
". a3fAr11fIGrII6 a �- •
?!. :
-cam — DEPARTMENT OP BUILDING INSPECTIONS
212 Main Strcct ' Municipal Building r --
Northampton, Mass. 01060 r'
WOPQ R'S COMPENSATION 'MS U'RANCF AFFJ)AVrIT
L, — P.IiSL6 @ R• 2• _,i4QQfin.-......._
( liamscdpermittcc) - —
■.rith a principal place of businessiresidence at:
Flo NOine,A\Le.. / EastharnrytOn .MA mail (phone)(- Y13).s97- /75 .
(sfrciJd �a.dap)
do hereby certify, under the pains and penalties of perjury, Thal
(V I am an employer providing the following worker's compensation coverage for lily
employees wor nng on this job
2 ,i heJk Jib 1 th al WC5 - a3171Qq -033 1 0/E /O
caste = Connanv) (Policy •urnbcr) ()piruon Dan)
( ) I am a sole proprietor, general contractor or homeowner (circie one) and have hired
the cone actors listed below wbo have the following worker's compensztion policies:
(Nnmc of Contractor) (InRranc: CompastyiPohci Nu incT) (E xpintuon Date)
(Namc of Contracor) (Insurance Company PoUcy N11.rnccr) (Lvpuetion Dale) .
(Name of Cona (Insurance Company/Policy Namb:.r) (Expiration Date)
•
(Name of Contractor) (Insurance Comoacy/Policy Number) (Ex Date)
(.a.th i ocs.l dcct •f peer -tAry to 'Incwec inform oo pertaiaias to .11 eom-o.CO )
( ) I am a sole proprietor and bave no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE: Pi =-44 lx evrire thzz' boon o++ocrs wtro employ pc-sous w LSO r. • c===:eroo r renir .•oric ere ads "cJ.lx ` of
am tDOC' tom. t ` . 1": tmla to with the bomoowoc resd0 or co the c ouo` , zppurtmer= tb o —c Dot C'Jo i1y ooCrr:d to be
employ uodre tic w e-kee: c s-'Jm Aa (GL152s31(5)), appliaaoo by . bomooaaa fox c lire a pcsmrt n:Oy c.idmoc trc
los:J rtt , of .a o ployer uodcr tbo Workcet Work -'t Co apomaiioa Act_
I sonde rt.ad thsa . Dopy of tbi, mtcmcm ta.y bo forwwrded to Lbo O•gonmeoa of l",4. rrisi Accdca>' Moo of L, .t,.noe for tit.
covazsc vrnf boa Laid th1 Lilt= to soave bovc asp tmdrs s.oeiioa 25A of MDL 152 no load to the i ,,osi ioo of mmialtl peo-thU°
oocaissszs of a riff of up to 51.500.00 .Mf c Carprisooasen of up to ooc year rand civil pasahia io de form of. Stop Wort Or and .
arte of 5100.00 a thy aptinA t»c
For dcp.rtm'ai soar on1Y
- —r --__\., ivizpu — Lot r __
Signatur of Licanscc/Pcrmiucc L)3te . .. -. _...
SECTION 8 ,,CONST C
•
•
RITIO
ERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
V
Name of License Holder : '1w` . l e / is l e. g7. / 33-Y
License Number
' /I I • r - •_ .Cal ys I. 5 - ,3 - p'
Address / Expiration Date
l ( 5f27 - �� 75
Signature Telephone
r" Ra `"ter` a §N.om'e lm.r• emen TCon r:.'c:t'e . �_ ` A; :10„ . Not Applicable ❑
R. 0 I. Roof', r9 /ab235
Company Name Registration Number
n AV era e - e o . t3ox ,30 I 5 - b - 0)4
Address Expiration Date
Fos- I- m.)7ton tM R O 10g. r1 • Telephone ("{ ► 3 5,`7 --
•
•SECTIOIJIO 'WORKERS' COMPENSATION INSURANCE AFFI DAVIIT (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 ❑
=0111 t E J
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 a tt-ani1pd
•
SECTION 'i= D 5 R ONA .
•
•
•
RROROSEDIr ch Tl i s applaca
P,T ° V
: _.. _ . , ..,.,o ....,g , . ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: RP existi skin 7ns-t rxlllf.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
5a IfiNT„Wan us'e' andri f a"dd.itton t ex°tstin :frOUSing; co PEtae th'e fo `lowil g:
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. I s 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
.� � . :d5u •kp,ih.. a'st q fk � ._ }
SECTIO g &bi E I ti RIZATION y TO BE COMPLETED WHEN
OWNERS GE �1OR ONTRACTO APPI_!ES FOR;BUILDING PBI�MIT
, , as Owner of the subject property
hereby authorize il 11.1 ' I - U7 r. 4 • • . f to act on
my behalf, in all matters relative to work authorized by this building permit appl cation.
ofi±,Qfv 'r 12- a-03
Signature of Owner Date
I, .i 4.1 >; • iS I Q •• _'s. I • '.t , as Owner /Authorized Agent
hereby declare that the statements and information on the fo - going application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
I 1 ' -
Print Name
is -a -o3
Signature of Owner /Agent 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
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 describe size, type and location:
•
•
City of Northampton
Building Department
212 Main Street
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
1.1 Property Address: • 7h tro to be fit o I tr by f ic
3O '�IT�'�{ /� y� /� G CTL N ,[� D JIB t
1 JI LI./ll.�J CJ 1 JI.L C.� d aa, +t t�t s � � z .. ,� t
Zone '� Over a moo' tr►ct - �'
Elr St District CB Dis rct
•
SECTION 2 - ` PROPERTY OWNERSHIP /AUTHO AGENT
2.1 Owner of Record:
J-kn.b Goldsmi+h 30 1 1 : narui.s Street
Name (Print) Current Mailing Address:
atta P hPri . e -1
6
Telephone
Signature
2.2 Authorized Agent:
Noxc 17e /;slf, - f. C. I. foofi n 9 Pa. Lax 309 - Ec6iharnpfi .MA
Name (Print) Current Mailin g Address: 1 01Ox,7
(-9 / 3 527- 141/75
Signature P
Tele hone
SECTION .3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official'Use Orly
completed by permit applicant
. Building I
ROOF l n3 900 ,�� (a) Building Permit Fee
2 Ele c.rical (b) Estimated Total Cost of
Construction from
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
l
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 41 6,100.00 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
30 FRANCIS ST BP- 2004 -0661
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 098 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2004 -0661
Project # JS- 2004 -0949
Est. Cost: $6900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 7492.32 Owner: GOLDSMITH HERBERT B & CHARLOTT
Zoning: URB Applicant: RCI ROOFING
AT: 30 FRANCIS ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527 -4775 Workers
Compensation
EASTHAMPTONMA01027 -0309 ISSUED ON:12/5/03 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 12/5/03 0:00:00 4878 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo