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DEPARTMENT OP [BUILDING INSPECT10fdS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 "+
WOMCLR'S COMTENSA'MN LNSUIZA_NCE A < , ANTIT
(li ccuscrlpermi ttcc)
V1'1Lh a principal place of business/residence at:
(stT�.t/ci ty/stalcfz�p)
do hereby certify, under the pans and penalties Of pegury, _hat
( ) I am an employer providing the followinL workers compens�-%non covc,-ZQ for my
eluployces worlOng on Otis job
(nszrr-`nc_- Comprny) (Policy Numirr) ----- () ,pinion, Daic)
( ) I a-m a sole proprietor, general contractor or homeowner (circle on and have hired
the contractors listed below who hive the following worker's comnen_,� non policies:
(Name of Contmclo') Onssumnc Companyif)o6 ,- ?NtUMIYY-) Datc)
(Name of Contractor) (Insurance CompaayiPolicy Numcrr) (Expi-con Date)
(Name of Conn-acio,) ORRLrancc Compan)'/POUC�- Nwnber) (Bpimaoo Date)
(Name of Contractor) Rnsu=c-- Company/Policy Numbs) (Expiration Date)
(mach adli:iocal c'xr1 ilocccun to Qic!u�uiformihoo pertaining to aL oca7-�c_o:�)
I am a sole proprietor and have no one worLiog for me.
/( � I am.a home owner performing all the work myself.
NOTE:plr be nw>c ty,,.11.Je bcmc_ouvc wbo employ pc,-iom w do o:FrPau Norm oo of
nM—th•n r L-a?-in%IiD fl lb,twiU—,--' ,I,=id,oC oo LbC Q'oLLn43 2p pwico =thC' LT ooe oC-C3.' -Md to be
employez untie-the t.'O{; oca�tien Act(GL157ss 1(5)�application by a bomeoavcr for c bc=,=a permit rayrd'. the
Ic-p.l ctnaic of en<azployx under die Workoe,CoaxpomaLion Aet
[u &rOand dut a copy of thi c2at®cut atay bo f,,,,ind to tbo Dcportmcna of In�i.frinl Ac+odm&Offioo of 6---for tba
oovcn.sc vcriGclioa artd ttt_.t L•iltat;to scauc oovczn�C tmdrs suction 25 A of hIOL 152 can lad to the irr;xis2ioa of crimiatl pcnaliics
oomiving of a Fmc of up to S 1,300.00 ardor mprisoon r, of up to one year tnd ci it pmiltto in tc form of n Stop Wort Order and e
EM 0(5 100.00 day i&inst CO,_-
For u_only -----------
�,��� Permit 1�it�1)c.r
Map;; — 1.01
Si ahtn otLicxnscclYcrnuucc —131=e
. CN 8`•CONSTRUCTION;SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
f ,5 Not Applicable ❑
Comps y Name ' Registration Number
Address/ Expiration Date
5f� 111. Telephone
SECTION 14 111tt?RKgRS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.p.152,§25C(5)) ,.
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
3
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: e—/o o✓e/- cm'e--
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ 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?
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
OW N Ft AUTHORIZATION-TO tX COMPkI TED WHEN
1N 1ER AO,E ,"t RCOt�TRAC ORAPPLIES"P R.�UILDING PERMIT i
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
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 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 Y
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 V
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:
a
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIQN 1 SITE tNf O.RMATtON
1.1 Property Address: yyy
ge.�� r
777777
�itli 2 PRt?PEI�7`Y OWNERSHI, UTH43l�I AGENT
2.1 Owner of Record:
Name(Print) Current Mailin Address:
�-
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
CTI }N TI C ED+t CII�TRUI N COSTS
Item Estimated Cost(Dollars)to beficielts�en%
completed by ermit applicant
1. Building (a)Bui ding Perrhit,pee
2. Electrical (b) Estimated Tonal"Cast of
Construction from 6.
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) 7, 00_Bd Chec�Vuhiber
This 6ec#iorf For Official'Use Only
'B Rollg P#rmitNumber: Date Issued:
Eiiiildirrgarmissit. rfirisectolrf Buildlgs . " Cate
w.+r--
26 DREWSEN DR BP-2001-01 70
GIS#: COMMONWEALTH OF MASSACHUSETTS
rk'AMIBlock: 35- 116 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0170
Project# JS-2001-0281
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD BOYNTON 126807
Lot Size(sg.ft.): 8755.56 Owner: COSTELLA RAYMOND A&DIANE M
Zoning: SR Applicant: TODD BOYNTON
AT. 26 DREWSEN DR
Applicant Address: Phone: Insurance:
83 SILVER ST (413) 772-8829
GREENFIELDMA01301 ISSUED ON.8116100 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER EXISTING 1 LAYER
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 8/16/00 0:00:00 1544 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo