29-344 (2) O
at� of wart 11amptoll
9 6 �asaacfinsctta'
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060 '
WORKER'S COMPENSATTON INSURANCE Arl MAVU
with a principal place of business/residence at:
J I0 �/✓ fr� =_� (Ph Onell)
(streeUcity/stat chip)
do hereby certify, under the pains and penalties of perJtlry, that.
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Compaiiy) (Policy Number) (Expiration Daze)
O 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 Corupany/Policy Number) (Expiration Date)
.,
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compa*ry/Polie�Number) (Expiration Date)
(attach additional sSctt ifncc�z to inchsdc iafocnuIIoa patainins to all OXI-Iracters)
O I am a sole proprietor and have no one «orking for me.
�I am a home owner performing all the work myself-.
NOTE:please be aware that while hcmcowrxrs who employ pcn,-,.s to do rrxiatcaance,oxzuruaion or repair work on a dwelling of
not morro than thtoo units in wtricfr the kxcrmoowncr midcs a on the p uu.3 xppurtt=Ij tha-do arc no(gcncrztty oomida cd to be
miploy—under the--k&s oxnpenzation Act(GL152,ss 1(5)�rpWL--tion by a homcoavcr for a Lccux cc permit may cvidcnoc the
ltgal rinhia of an omployer under the Workcet Componsat Ac
I uaderaund that a oopy of thin rutemcat usay bo forwarded to tho Dcpartmaoa of Industrial Aecidm&Of Goe of tnsivanaa for the
oovcsagc vaificalion and that failure to&o=m coverngo under soctoa 25A of MGL 152 can lead to the impom ion of criminal pcnaltfes
000sisting of a fine'of up to S 1,500.00 and/or iriprisounxni of up to one year and civil pcnRl6a in the form of a Stop Work Ord—t and a
fum of S 100.00 a day tgaiast me-
/
For dcputm Number
Daly
Permit Numm ber
c T&PIt Lot's
Signature of Liccnsec/ crmittce e
SECTIONCOISTRUCTION:SERYICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
r m .fm r uerrien n`rac r? !!MFR µ 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 affida
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)familie
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(
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
DES POSE OFPROPOSEDWORKhecII is licable�
,,. aw31
.. .,.r..„ P.._.. .3..,u _. .._.. ._..�:.�• .Fr�,� ,,, ur, .3=.3h'1 1,�?.ink
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing \,e(
Or Doors ❑ J�
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a�If�New�h o`use` a-rrdor�adtlition�toex�stinliousing corripletethe follow�in :
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
is Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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 7?i OWNER AUTHORIZATION :TO BE COMPLETED WHEN
OYYNEI2S AGENT OR C;ONTRACT0�2;APPLIES POR' UILb11VG PERMIT
as Owner of the subject proper
hereby authorize to ac
my behalf, in all matters relative tow k authorized' by this building permit application.
i� �4�� , �� -, ;?�
nature of Owner D e
l 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
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 YES, describe size, type and location:
• r
V
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 e s
phone 413-587.1240 Fax 413-587-1272_ PSte
<Ot e,�Spe,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 -SITE INFORMATION
This sec#ion to be completed by gffice
1.1 Property Address:
)y� ,�/f� `?�� //•y1 Map Unrt � �
=Zone ° � ��Ouerlay�Distrtct � K"�
r1« e 1--i c Lo .
Elrn St District CB Dist`r`ict
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECT1ON.3 - ESTIMATED°CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only -_
completed by ermit applicant
1. Building 1 5yo (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
Building.Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector ofBuildings Date,,,
BP-2002-0161
GIS#: COMMONWEALTH OF MASSACHUSETTS
- � k:29 CITY OF NORTHAMPTON
-.344,
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0161
Project# JS-2002-0264
Est.Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: _
Lot Size(sq. ft.): 19732.68 Owner: EASTMAN GLENN A
Zoning.URA Applicant. EASTMAN GLENN A
AT. 94 AUSTIN CIR
Applicant Address: Phone: Insurance:
94 AUSTIN CIR
FLORENCEMA01062 ISSUED ON.81131010:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SH I NG LE ROOF
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 8/13/010:00:00 2236 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo