29-526 (2) 4�11A14P�0
O � e
�a4f Atljnfr114
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(ll CeIISC�perIIll ttee}
with a principal place of business/residence at:
(phone#) � -UZC=
(stl=Ucity/sta&7ip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers 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) (Exp ratioa Date)
r.
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Ex-pirabon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additional shoed ifneoenary to iochsde information pextaiuing to all minder)
( ) I am a sole proprietor and have no one workillg for me.
( ) I am a home owner performing all the work myself.
NOTE:pleaac be aware that while bomcownm who ezaplay pasaas to do ala_intcxa con:stn=oocrrcparwu rk on a dwelling of
not mcce than three units is which the bomcownrr midcs or on the grounds appurtenard thereto arc no(gcocra.4 ooasidacd to be
employers under the worker's c= cusation Ad(GL152,=1(5)�application by n homcownir for a keener cc permit may cvidcnoo the
legal stxtua of an employer under the Workoe'a Compooaation AcL
I un&rstand dirt a copy of this statement miy be focworded to the Dcpe.,ft at of In&uo"i l Aecid=&Offioo of lasivanoe for the
coven vaificalioa and that failure to stc=covcmp tnoder sociioa 25A of MOL 152 can lead to tbd imposition of criminal penalties
ootnisting of a f oc of up to S1,500.00 and/or im priso�of tip to ono year and civil pcnattia in the form of a Stop Work Odder and a
f=of 5100.00 a day againA mc.
For dqurtm�►u>d oaly
permit Number
v G�— Wpb{ Lot#
Signature of Licensee/Pe tree Late
w
SECTION 8=CON5TRUCTI,ON SERVICES'`
8.1 Licensed Construction Supervisor: Not Applicable ❑
NaALicense Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION to .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 DwellinES 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 buildinil 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
w �
SECTI�O�NxSSCIP= ONFP�R` POSEDWOR ce 'all a licable R
........... 3 I 3»Z,iAu
ff �
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: E c ,31411V&ees
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
Y:e:, o flit "WHmi coim"°1# °` M1
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 ' OW,NER AUTHORIZATION-TO BE COMPLETED ,WHEN
OWNI=RS,AG fT�OCONTRACTOR Api'IIES FOR' UIL DING PERMIT
l 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
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.
Print Name
o2
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 a
Frontage �f
Setbacks Front /.
Side L: R:la L: R:
i
Rear 2o
Building Height /e r
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)'7r
#of Parking Spaces L
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:
'ty of Northampton
ild'ing Department
212 Main Street
E y I Room 100
APR I hampton, MA 01060
phone 113 87-1240 Fax 413.587.1272
UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION.
1.1 Property Address:
lk4l�3_1
Thiss�ectr 't etc` p
6E Zone
Elm St. District CB D�stnct =x.
SECTION"2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record-
Name(Print) Current Mailing Address:
{ fi_CrC'ECL�
' Telephone
Signature jN `�j —(� L lc,£ W J�� — 2.3 c°
2.2 Authorized Agent:
2- 1
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 (a) Building Permit Fee
2. Electrical (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
Btuilding Permit Number: Date Issued:-
Srgnture
'wilding Commissioner/Inspector ofBuildings Date,,.
left
25 GREGORY LANE BP-2002-0868
GIS#: COMMONWEALTH OF ASSACHUSETTS
Map:Block:29-526 CITY OF NORTHA 4PTON
Lot: -001
Permit: Building
Category:roofin g
BUILDING PERMIT
Permit# BP-2002-0868
Project# JS-2002-1439
Est. Cost: $1300.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg.1): 5880.60 Owner: KOWITZ KARL
Zonin,jz.URA Applicant: KOWITZ KARL
AT. 25 GREGORY LANE
Applicant Address: Phone: Insurance:
25 GREGORY LANE (413) 587-0268 0
FLORENCEMA01062 ISSUED ON:4116102 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & S H I N G L E 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/16/02 0:00:00 215 $0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo