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m DEPARTMENT OF BUILDDT G INSPECTIONS
212 Main Street Municipal Building
Northampton, Mass. 01060 '
WORI{LR'S COWENSATTON INSURANCE AFFIDAVIT
«� leperm�tiee)
with a principal place of business/r
V� 140 -f-.P/V,, hone#
ff (P }
(strreUci ty/staie/a p)
k-----do hereby certify, under the pains and penalties of pcgwy, that
( ) I am an employer providing the follollving 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/Poky Number) (Expiration Date)
.f
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsurance Company/PoEcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExpL-ation Date)
(atlach additional slid if no cnary to include informati on prstaining to all ooatradora)
( ) 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 homcowvm who cmplay pazo s to do ntainfrnsnet c=strumoo or rtpair work on a dwelling of
not mom than throo units in which the homeowocr resides oc on the grounds appurtenant thereto arc not ecnaaUy ooatidatd to be
employcm 11 tho tvor�.compcm tioa Ad(GL152,=1(5)),application by a homeowner for a liecasc cc permit may evidence tho
legal status of an employer under the Woriceet compomation AZL
I understand that a copy of thin rtalcmmt may be foswwded to tho Dcpatta ns of Industrial Accidents'Ofboo of Insruwoc for the
coverage vmficatioo and that failure to aecutt cove t under sccUoa 25A of MGL 152 can lead to the impos¢on of aiminsl penalties
eomisting of a fine of up to S 1,500.00 and/or of up to one.year and avl7 pcaattia in the form of it Stop Work order and a
fun of S 100.00 a day tpiast true
I For dcp=r uao only
Permit Number
2 a B t MaO Lot#
Signature o LicenseelPermittee Date
SECTION 8 CONSTRUCT ION SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
# q, n#N
� Fte eredmemprgvement>.Contractor. R ,x .,... , 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 affid�
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
O wA- eT { fie pt on.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familic
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(
you hire to perform work for you under this permit.
The ersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
N ampton Ordinances,2Lanl Local oning Laws and State o ssachusetts General Laws Annotated.
Homeowner Signature t
SECTION OESCRIP<TIONQF�PROPOSED WORK icheck gall�apalicab
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors,
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Le cA Z
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement _ Yes No
Plans Attached Roll ❑- Sheet❑
6a If New douse a"hd or ,tddition'to�existing h' sin14, complete the Poll"owin` :
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?
In. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain _Yes i
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
SECTIION 7a rOWNERAU7HORIZATION TO BE COMPLETED WHEN
OWNERS'AGENT OR',CQNTRA�CTOR'APPLIES°FOR;BUILDING PERMIT
as Owner of the subject proper',
hereby authorize to act
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.
e 0.qr- �� �cvkJ l9 D r0 u
P int ame � � � 49-y
41 -A '.
Signature of wner/Agent ate
i
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
L Si
Fro e
Se acks 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:
r
i
IF YES: Was the permit recorded at the Registry of Deeds?
r
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 4f' 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:
1
City of Northampton,
Building Department Curb
212 Main Street
Room 100 Waterell ,' fib Ia
Northampton, MA 01060 TSwoSetsofitr c� ans
phone 413.587.1240 Fax 413-587-1272 Plot/Site PIa s
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be completed by office
.1 Property Address:
Map Lot �� Unit
[�1 �� Zone Overlay Districf
r I Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature —
2.2 Authorized Agent:
ame( rint) �' r Current Mailing Address: � -
n Y 6—' t Y� c9 Q .r0 u l� S Y 7�f� /` ,, 1 10-v e4w,c vn4
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'' b
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:.
Date:
' Building Commissioner/Inspector of Buildings..
J
16 p BP-2001-1124
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2001-1124
Project# JS-2001-1975
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 29577.24 Owner., SCARBOROUGH HENRY F&LUCILLE
Zoning: SR Applicant. SCARBOROUGH HENRY F & LUCILLE
AT. 764 RYAN RD
Applicant Address: Phone: Insurance:
764 RYAN RD (413) 584-2105 ()
FLORENCEMA01062 ISSUED ON.61281010:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE TWO DOUBLE WINDOWS
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 Sianature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/28/010:00:00 3809 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo