29-335 v" !
a..
-�tiMfPT
s atx zx nrz i�tt�it$r uit ^
� B f�lassxchnsctta
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AF' AVIT
(licenseeJpezmittee)
with a principal place of business/residence at:
(phonet#)
(s tree Uci ty/stair/ri p)
do hereby certify, under the pains and penalties of pegury, that:
O I am an employer providing the following workerjs compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
the le proprietor, eneral contractor c r homeowner](circle one) and have hired
contractors fisted below who have the following workePs compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
+r
(Name of Contractor) (Insurance Compar y/Policy Number) (Expiration Date)
(Nau1e of Contractor) (Insurance Compariy/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Ezpiration Date)
(attac3l a&41 t 0cul sheet f n<reszuy to inchudc informj6oa pertaining to all ccatra'C on)
O I am a sole proprietor and have no one v',rorld"ng for me.
( I am a home owner performing all the work myself.
NOTE:ptcase be aware that while homcowixr3 who employ per-cans to do mAjuica ,, wastrur oe IT rtpair work on a dwelling of
not more than thtro units in which the homoouvcr r tildes or co tbo I,zounds appurtenant thacto arc oot stneralty oomidatd to be
employtrs under the woricces oe Tc=atico Act(GL152,ss 1(5)�application by a homrowncr for a Berme or pcim may evidence the
legal data o£an omployer undertb,o Woukcet Comp Ation ALt
I underA,nd that a copy of this ctatcmcoi may be forwnrdod to tho Dcpartnxat of Io&Ls4ial A.&.&OfGoo of lm-u for tho
coverage vtxifieatioa and that failure to uxttrt coverngo tinder suction 25A of MGL 152 can lead to the impositioa of mmi[W penalties
oomistiag of a fine of up to S 1,300.00 and/or imprisoama of up to onc ytar and civil pcaaltics in the form of a Stop Work Order and a
fum of 5100.00 a day against me
For&P-twm tiro poly
� Permit Number
0 Lot#
4 :. Si of Liccnsee/permittee
r
SECTION 8-=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
,�,y: ;� Not Applicable ❑
�Re";s�'�re�ll��mm rquemen��C4ntr"actor �, , - ,;��F_,
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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...... ❑
, Hnm: wneiEgemp. �.
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 a d State of Massac setts General Laws Annotated.
Homeowner Signature
n t
I
SECTION 5=.DESCRiPTIONAF®PROPOSED WORK'(check,all'applicable) .
a3�.f
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: e" 14 i�O
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a IUNew ho 6—77-M&T c omple"teethe followin>�:
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 QWNER AU N
THORIZATIO -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTR"ACTOR APPLIES FOR BUILDING 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
, 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 /f
Signature of Owner/Agent Date
s
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 0 C. '�L-�' C
Frontage
Setbacks Front
Side L: ( H�' R: \ .fr L: R:
Rear1
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?
ENO 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? C, 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 O
(N
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
ISO —
IF YES, describe size, type and location:
� � .
1
�^ ,� �;..
� � ,,it
i S
.H._ .:=. ... r:�u
��
! .., r„.
t ,
4
*� ;�
EC Northampton `S
DI g Department r
Main Street '5 �r 'e .► .
SEP — 5 2002 oom 100 e, ..
Northarr pton, MA 01060 AT a
DEPT E
87 240 Fax 413-587-1272 1?
Of BU1L
NORTHAMPTON,MA 01060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectionto be completed by office
1.1 Property Address: '
II� Lot� �
-A C Zone OverlayDistr ct R � `
��n fir C- ELY ICS
Elm St. District CB District
SECTION 2= PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ra �Y'.rz,f r!7 y �` nt". ��t7 i';L NC e 1�.9-rtc6-L
Name(Print) Current Mailing Address:
x �r Telephone 1
Sign- re 'SVI A1`3 C 3 _
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 _ (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 of Buildings Date
244ACItEBR, DR i BP-2003-0241
GIS#: COMMONWEALTH OF MASSACHUSETTS
( : 3s CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003.0241
Proiect# JS-2003-0423
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(ss . ft.): 10018.80 Owner: ALVARDO JOSE ANTONIO&YOLANDA
Zoning:URA Applicant: ALVARDO JOSE ANTONIO & YOLANDA
AT. 244 ACREBROOK DR
Applicant Address: Phone: Insurance:
244 ACREBROOK DR (413) 584-6363 O
FLORENCEMA01062 ISSUED ON:919102 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/9/02 0:00:00 4796 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo