35-115 (2) 4.�11ANP��
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
a► lerm�ttel-)
with a principal place of business(/residence at:
-77! �d' CY4(l1 � (phone#)
(str eef/city/stale/gip)
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:
(la=ce 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 Numbcr) (Expiration Date)
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(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparly/Policy Number) (Expiration Date)
(Naive of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(auad,additioall slxci ifnaccairy to indudc iafbaneion pertaiuing to all coaract0r3)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performina all the work myself.
NOTE:plcaac be aware that while homeowners who employ pczoai to&mxintcaancr,p,:7u on or repair work on a dwttag of
not moce than thmo uni}s in windy the homeowner rtaides oc oa ah groun<:s app utenarri thcc o a c oo(generally COmidcrcd to bt
cmploycr5 under the woricc s ooatpcasatim Ad(GL152"1(5)),nppliration by a homooavcr form Eccwe,cc r>Umit may evidcnoe tlx
leg21 rt2;u"of an omployec under dw Woricoes Oonspens tl Alt
I underz d thzi a copy of this ciatemcni may bo forwarded to the Dc4xi,n of lndiuirial Aaidca&Offroo of Imtu-m—for tbo
covcmg vaificatioo and that failure to ac covcrngo undx sccdoa 25A of MOIL 152 can Itrd to tho imposition of criminal pcnaJtica
oomisting of a frnc of up to S 1,500.60 and/or k4 isossmcni of up to one year and civil p""16a in tbc focm of a stop Work Ord--and a
fine of S 100.00 a day tgninst m
Foe degrrtnrc3sl uzo Daly
/aV
Permit Number
7 2vLap=t Lot#
tgnahtre of Liccn.SecRermittCe hae
SEC�T��bNi�L��ONSTRUCTION--SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder �'
License Number
� - I4
Address Expiration Date
C 0 "� 2
Signature Telephone
e:. m veme� r _ Not Applicable ❑
C
Company Name n Regis rt ation Numb r
`-7C ���rl fl J✓ G � c
Address Expiration D to
Telephone
SECTION 10-'W RKERS' 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-vear 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 pen-nit 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
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ECTION S DESCRI PTT 1�0W0`F PR�OPOSED�W�RK� C#i"ck a11'a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding L� Other [ ]
Brief Description of Proposed Work: L''1 S C L Si q ?
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet o
>aa If�New'olio'�iiseandor"` ddition�#o` existing' housing,-�corriplete�tYiie fol.la' 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
i. 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
SECTION7a-,OWNER:AUTHORIZATION TO'BECOMPLETED WHEN
OWNERS AGENT OR':CONTR'ACTOR APPI:`IES tOk"BUJLDING PERMIT
as Owner of the subject proper
hereby authorize 'its' C(,ti ��^ to ac?
my behalf, in all matters rel e to work authorized by this building permit application.
Signature of Owner Date
I,
�, ��� � 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 pa and penalties of periLLry.
C .iv"
Print Name '1�
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:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 1'.
phone 413.587-1240 Fax 413-587-1272 F'ldvsiie
ether&Sp
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be complet4l'*office
1.1 Property Address: n _ �
Ma p �
Lot 4 � kJt
cf' A44 -o- Zone A `Overlay D1strcct
Elm St. District CB District'r,
.
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Maili d r ss:
Telephone
Signature
2.2 Authori d ent:
Name(Print) Current Mailing Address:
ey� � _
�_
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) , C;'O Check Number
This Section For Official Use Only
Building;Permit Number: Date issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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77 FOREST GLEN DR BP-2002.0667
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 115 CITY OF NORTHAMPTON
Lot:-001
Pemut: Building
Category:vin Isiding BUILDING PERMIT
Permit# BP-20p2-0667
Project# JS-2001-1907
Est.Cost:$1200.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class; Contractor. License:
Use Group; Paul McCutcheon 100218
Lot Size(s�.ft. 13982.76 Owner• MCCUTCHEON PAUL C&MARCHELE
zonins:L►R4 Applicant.- Paul McCutcheon
AL 77 FOREST GLEN DR
Applicant Address: Phone: Insurance:
77 FOREST GLEN RD (413) 584-3352
FLORENCEMA01062 ISSUED ON:1122102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 Deilartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Oj{ Al- /
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAIVM' 0— ' t7� VI&ATION OF
ANY OF ITS RULES AND REGULATIONS. .ter
Ce t ficate of-Occ nc _ i natur
/�
.Fee TvOe: Receipt No: Date Paid: Check No:Af Amount:
Building 1/22/02 0:00:00 5151 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1'272
Building Commissioner-Anthony Patillo