35-179 ,
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9 GZt� of NDxt(1alliptoll
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m DEPARTMENT OF BUIL NNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORTCER'S COMPENSATTON INSURANCE AFFEDAVIT
(IicenserJpermittec)
with a principal place of business/residence at:
(phone#)
(s t m_-Uci ty/;atehi p)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insi rangy Company) (Policy Number) (Expiration Date)
( ) 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 Coiupany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expirltion Date)
(Name of Contractor) (Insuaancz. Company/Policy Number) (Papimbon Date)
(Name of Contractor) (Insurance Company/Policy Numbu) (ExT�_—tion Date)
(attach additioclil to tnlbnnitioa pcstaming to all Inc ora)
KI 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 homcowixn who employ per;,am to do trai„+ • oofr jctloo CT repair work on a dwelling of
not mote then throa units in wbicfi the rmdca or oa the gourds zppurtcnaat thcj t arc oo(g�y 0(a idcrcd to be
cmploytxs under the wor�s comper=tion Act(GL152,n 1(5)),application by a hotnr_owna for a Been-or permd may evidence the
legal rtatus of an amployoc under tho workcle Comporisat Act
I understand that a copy of this ctat=coi awy bo forwarded to tho Departma,a of 1n61S jd Aoad—&Offioo of lnsrusnce for tho
aovcsagc vai&catioa and that failure to secure oovcrago undcr,IX oa 25A of MGL 152 can lead to tha imposition of c6mma1 peamJEca
oomisting of a fmc of up to S1,300.00 and/or im;nisoamcat of up to ow yrsr and civil pcnaltia in 6c form of a Stop Work Order and a
faro of 5100.00 a day tg&iwt mc.
For dq utma�l use only
f Permit Number
f"
, i Lot
M #
Si c of Liccnscclpermittce e .
SECTION 8 -:CONSTRUCTION!SERVICES
8.1 Licensed Construction Supervisor: Not Applicablex
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
€_ rc �_ �E ...; Mma - �� s
:Reams redome m' r vemen �. n ra.. r. �„ g ,a,„ _,, ,�,, 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....... 0 No...... 0
3
11: .Home.OwnexrE mpttoll
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' Cc npensation) 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_ nd Local Zoning Laws and State of Massachusetts General Laws Annotated.
r � ,
Homeowner Signature % "�
SECTION 5' DES�CRIPT"IONgOF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing J
Or Doors ❑ ' \
I
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
i Brief Description of Proposed Work, T�'fif�'lr,Gl7
LV
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
s43 lfgNei.Wo"nt T; 'd o 'dditi6 to J§tiffitL housing, ,
completM6—" 611-dWini7:
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 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 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS;AGENT-OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize __ ____ to act on
my behalf, in all matters relative to work authorized tDy 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.
Print me
Sigr,Ature 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:/,,,)11 R:,,(Z L: R:
Rear 2/> Gl
Building Height c�
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 _X _ 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
Nox
IF YES, describe size, type and location:
f Northampton
it i g Department r
GL t Main Street
` I oom 100
�,.NolAham ton, MA 01060
1.iht5�t ='587 1240 Fax 413-587-1272 ? to
03therSpecrjr
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I SECTION 1 - SITE INFORMATION
'This section to,be completed by office
1.1 Property Address: of
`
�• / J/ j� .✓ .+n Map ' ].pt r ' un7t
Zone Overlay District � 6
Elm St. District CB District
Fs 2 - PROPERTY OWNERSHIP/AUTHORIZED-AGENT
i 2.1 Owner of Record:
t
= � L� X
a (Print) Cura: ailin ddr ss:e
�lephone (?� �' --p l 'r Im1'e 6-
Sign- ure
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 ,i (a) Building Permit Fee
2. Electrical (b) Estimated Tc;.al Cost of
Constructioi 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:
Signature:
Building Commissioner/Inspector of Buildings Date
` r
7 PINE VALLEY RD BP-2002.0781
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 179 CITY OF NORTHAMPTON
Lot: -001
Permit: Building?
Category:roofing BUILDING PERMIT
Permit# BP-2002-0781
Project# JS-2002-1301
Est. Cost: $4300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(ss . ft.): 93218.40 Owner: SCHORGE RAYMOND G&CAROLYN V
Zoning: SR Applicant: SCHORGE RAYMOND G & CAROLYN V
AT. 7 PINE VALLEY RD
Applicant Address: Phone: Insurance:
7 PINE VALLEY RD (413) 585-9151 O
FLORENCEMA01062 ISSUED ON:3119102 0:00:00
TO PERFORM THE FOLLOWING WORK.ST R I P & SHINGLE ROOF
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/19/02 0:00:00 932 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
7 PINE VALLEY RD BP-2002-0781
G1S#: COMMONWEALTH OF MASSACHUSETTS
a :Block:35= 179 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Gategoort+.roofing 'BUILDING PERMIT
Permit# BP-2002 0781
Project# x-2902-1301
Est.Cost:$43Q0.Q0
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
use Gronlr
1&t Size(w.ift. : 9321,8.40 Own-en SCHORGE RAYMOND G&CAROLYN V
?ogg_SR Ap mi SCI-8QE RAYM0NE7 G CAROLYN V
AE 7 PlNE-VALLEY Rfl—
Annlicant Address:
Phone. Insu ancee:
7 PIKE VALLEY RD X413) 585-9151
FLORENCEMA01062 IS UED QN.&I912 0:00:00
TOPER FO"THE FOLLOWNG WORK.-STRIP & SHINGLE ROOF
POST THIS CARD SO 11,J&YISIB�I.E FROM THEE STREET
Inspector of PlumMug Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough. Rough. # Horse# Foundation:
Drlveway Final:
Final: Final: :<
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough:- t?il: Insulation:
Final: n oke• Final:or j(,` �
THIS PERMIT MAY BE REVOKED BY THE C OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Qer-tifigat!p,gf QgQ1jPAJ3Qt r
Fee e: ' I Noc Date Paid: Check No: Amo t:
Building 3119/02 0:00:00 932 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo