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29-202 �-(II"f P�, Ago � 0ti� 61t�) of Po tllalliptoil 9 E QIxssnchncctIo = __ w DEPARTMENT OP DUIL,DP\IG INSPECTIONS 212 Alain Street ' Municipal Building Northampton, Mass. 01060 WORIQ,R'S COMPENSATION INSURANCE :�hl L�r1�rll' (l�ccu permittcc) v,11th a principal plat-- of busioess/residencc at. hone:' — .� I �cy�sca�cJap> do hereby certify, under the pains and penalties of perjury, .hal (V�/, aro an employer providing the following, work-cr's corrlocnsZzjon cove age for In), employees worming on Otis job. 1�t,ia.A J;)is Ivc 1-31 - 9,V7?/_ofo Os-/S-door (tasur Cocin��) (PeLic; No r) (rxpir uor, Date) O I am a sole proprietor, general contractor or homeowner (cucie one) i?nd have hired the contractors listed below who h2ve the 'MoWIDS worker's comnensanon policies (Name o, Cont Icto-) ComDan)-i-Pouc,, Nunes;) Date) (Name of Contractor) -- (Insurance ComDanv/Polic-v Nu-tnccr) FExpiMiion Date) (Name of Contractor) (L sw-ancz CompaoyfPolk}• Nutnb�i) (Expl-moon Date) (Name of Contractor) (Lnsu=c-- ComGamy/Pohcy Numbs) (E=xpiration Date) (coach addi:oczt slxci irncc xry to incur infonn-Lnoo pertainins to.-U ( ) I am a Sole proprietor and have no one wor4bng for me. ( ) I am.a home owner perforiuing all the work myself. NOTE:plc- c be nwuc tLe cmpioy pc ions to 5o r rL cam= ram a npav 'orx oo.d..<ll��of not mocc tb_n Lsoe ttnru inµ-c:b the lXHnO4N.rrvdo«cc Che Qou�zpputteautl the Go r c we ro ly a cridYaj to be cutployc-s undc the wcxka i om*�.a:tioa pct(GL152-sz 1(5)�application Ity t bomrowva far a t,csv«perma rn:y c-r&noc Lbc Icgr.l rtnnu of a -=Ptoyx undo din Wock.oe,compom—L; n A,--I- I unda-vt nd that a copy of Chi,aatem ut m.y be foe-m rd.ed to tbo DeVutm t of Indsc_,id Aeo&a&Ofl;oo of Irai+nnoo for the oovcrxsc vcrificaioa n-:td Ih:1 L•iltrc to soaarc kovcrn�under soctioa 25A of MOL 152 can Id to tln impos.600 of criminal pcasllic= coosL<ia8 of a fin--of up to 51,300.00 sndror kupri�ofup to ooc yvr tnd civil pmshio in be foctn of a Stop Work Ordu and e fim of S 100.00 a day t pima me For dgs.rtm='1 u.c only / Pcrtnit Nu mbcr �_- .Jl.� Adapt Lot Signature.of LiocnsccAlcn Um — -� SECTION''$-CONSTRUCTION SERVICES, 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: zi ,�O,tj /J 42 � �a /{® License Nurr I.,;IQ b 5� Address Expiration Date Signature Telephone Not Applicable ❑ �y 0 �G Company Name,,{( Registration Number Add�rr ss C� Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GJL.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 9f 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)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 S i be ' New House ❑ Addition ❑ Replaceme Windows Alteration(s) ❑ Roofing O Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding R4 Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 11 Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 S CTd4N 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OkyN1~�S AGENT OR�CONTRACTOR APPLIES,ObR5SUILDING'PERMIT /3 as Owner of the subject property hereby authorize d k).1 A) b`f to act on my ehalf, in all matters relative to work authorized,by his building permit application. Signature of Owner Date I, <1''W"3 L- /6 /:?A'O aster/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 Ems— C— 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 City of North on Building Dep n 9 2a 212 Main tre Room 1 0 DEPT DFBUI%pIPM Kl PEI'TI Northampton, I'VI phone 413-587.1240 Fax 413-587-1272v APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE-INFORMATION 1.1 Property Address: This tioby mp Y, ffte F ,, 4z /r i 1 ' oi'rla r�� rat SECTION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P 'nt) / Curreent Mailin&Address: -- - Telephone Signature — — ���y- U 9 3,; 2.2 Authorized Agent: zz'�*'�' ") L ql�� /Za/90 /0 4'+'�76 A) N�(Print) � Current Mailing,A(� ress: Signature Telephone SECTION''3-4710ATED,O©NSTRUCTION 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) /3 �6-0 0 —y Check'Number This Section for Official Use Only' Building Permit Number: Date Issued: Signature: '9411 ding Co mmissior►er/lnspector of Buildings Date 43 BEATTIE DR BP-2001-0495 GIS#: COMMONWEALTH OF MASSACHUSETTS *ft.Bock:29-202 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category^replacement windows/siding BUILDING PERMIT Permit# BP-2001-0495 Project# JS-2001-0853 Est.Cost:$13500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sg.ft.): 10454.40 Owner. BRIGGS LAWRENCE E JR&LOIS C Zoning: URA Applicant: B & R Siding AT.• 43 BEATTIE DR Applicant Address: Phone: Insurance. 781 Bridge Rd. (413)586-4167 Workers Compensation FLORENCEMA01062 ISSUED ON.•11 1I5100 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTLL REPLACEMENT WINDOWS & SIDING 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 Deaartment 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 11115100 0:00:00 17379 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo