35-082 (5) Q�IiAMPT0
6 �aisarf(nsrtla'
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 "
WORICER'S COMPENSATION INSURANCE AFMAVIT
(Iicensee/permi tt ee}
with a principal place of business/residence at:
(phone#)
(strce_Uci ty/statd2i p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
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 Company/Policy Number) (Expim6on Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheer if neccn ry to inchide iafannuion pertaining to all ooatm rs)
( ) I am a sole proprietor and have no one working for me-
I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowr)crs who employ person:to do=Liattaxacr,construction or repair wort;oo a dwelling of
not more than throe rails in which the honbowncr resides or oa the voua,h appurtenant tba cto arc not gcrxrally mandcred to be
employes under the worker's oc peus4on Act(GL152,s3 1(5)),application by a homeowner for a Uccu or pax m may nidcnco the
legal slutua of an employer under the Worlccet Compaoa&tiou Act
I undots d tbat a copy of this rYatcmcot may ba forwarded to the Dcpartasco2 of I.&Lbial Ao6d=&Qh&oe of 4mur co for the
coverage YaIGcation and that failure to&=M coverago undcr scc ioa 25A of MOL 152 can lad to th o imposition of criminal Penalties
oomistiug of a rme of up to S 1,500.00 andlor imprisoamrn of up to one year and civil pew riia in the form of a Stop W ork Order and a
fins of 5100.00 a day against ma
Foe nary
mat Number
use
Permit Ntlmbes
Signab=of Licensedpermittee
SECTION N$ ,.CONSTRUCTION SERVICES '
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
iffft
- S` x..s`� 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 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 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
SECTION 5 ,DESCRIPTION(OF PROPOSED WORK Check a,ll.applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑ 1
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other[v]•
Brief Description of Proposed Work:_ l ��" << �`° yva-�
Alteration of existing bedroom Yes No Adding new bedroom Yes V No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roil ❑- Sheet o
6a If Ne<. owe,ands K-Zaidd>tiddl o.eir1 ting;F ousi'ng, complete'th :follWn°
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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION 76 OWNER AUTHORIZATION -TO BE COMPLETED WHEN
QWNER5 AGENT OR CONTt2ACTOR APPLIESOR`BUIL:DING PERMIT
I, 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
C LrC%�
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
y/pains
//and
y penalties of perjury.
SA '�I "
I �I I
Print Name
Signature of caner/Agent Date
J
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
0 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 it DON'T KNOW YES
s
IF YES, date issued:
i 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 I/ 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:
{
City of Northampton
uilding Department
212 Main Street ►
` 4 202 Room 100
SAP `t No thampton, MA 01060 . e
413 87-1240 Fax 413-587-1272 e
DL QF aui�ol. �c�loy spec
MA 0106 O
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1:-SITE INFORMATION
1.1 Property Address: This sec.tfo° to be�c'ortipleted�by ftce °
P Map
4
�( eA ,/►/� 0 l b 6 Zoie �� " Overlay istrrc#
01
t
EImSt:"District CBD�tfrCct *' _
SECTION 2' PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
qa 0ren CC, �O
4-
Name(Print) Current Mailing Address:
' Telephone
.57q
Signature
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 permit 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:
3
Building Comrnissianerflnspector of Bu,tld�ngs
1255 BURTS PIT RD BP-2003.0303
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35 -082 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Categoa: BUILDING PERMIT
Permit# BP-2003-0303
Project# JS-2003-0517
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 17859.60 Owner: MCGRATH DANIEL&
Zoniniz: SR Applicant: MCGRATH DANIEL &
AT. 1255 BURTS PIT RD
Applicant Address: Phone: Insurance:
1255 BURTS PIT RD (413) 586-1579 (�
FLORENCEMA01062 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:I NSTALL WOODSTOVE
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:O`{
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee Type: Receipt No Date Paid: Check No: Amount:
Building 1084 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo