35-203 (3) t �CIIAMPT0
-
$ B �lssasch«setts
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AAFU'MAVTT
with a principal place of business/residence at:
o
(A=Ucity stalrlrip) o 10(p Z
do hereby certify, under the pains and penalties of perJury, that:
O I am an employer providing the following worker's compensation coverage for my
employees worEng on this job:
(Insurance 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 Company/Policy Number) (Fxpimtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional slxet if mccnixy to include infortnarion pertaining to all 000tr fs)
( r) I a sole proprietor and have no one worlisng for me.
I am a home owner performing all the work myself.
NOTE:please be aware that while homcovnm who employ pcnom to do mlk�construct oa or repair work on a dwelling of
not more than throe units in which the bomaowncr resides or oa the gtvunds appurtenant thereto me no(generally coesidcrcd to be
employers under the worker's oration Act(GL152-"1(5)},application by n homcownct for a Uc=c cc permit may-idcace the
legit ctatua of an employer under the Workeez Compensation Act_
I understand that a copy of this ctatcmcut may be forwarded to tbo Dcpertr.�of Di al Aocidcr,&OM oo of in—for tho
coverage verification and that failure to secure coverage sunder sociioa 25A of MGL 152 can lead to tho imposition of criminal p-&Wcs
oonsisting of a fine of up to S1,500.00 and/or i mp riso�t of tip to one year and avi pcaaltia in the form of a stop Wort:Ord--and a
Sim of:S 100.00 a day against mc.
* Foe dgr-t use only
permit Number
Lot
i`{ iPatare of LiccnseclPermittee Date
�. v10N SERVICES ��:
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
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 affidE
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)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 undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and cal Zoning Laws and State f Massachusetts General Laws Annotated.
Homeowner Signature
SECTIOND�ESCRPT PROPOSED1NOtK cIIEa' litalilej
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: rc C'{ S H c S f' ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
°'�IfNeho��`ise°' an+dotldit�on'to° ez�st�n hof�sin�.�c`omple'.tethe.r#o11o'wi; :
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
SECTION 7a OViINEReAUTi �ORIZATION TO BE COMPIETED WHEN
OWNERS AGENT:"QR CONTRACTOR APPLIES,-FOR BUILbIIVG 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
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 penal��'esp f perjury.
Print N e
Si a re of Owner/Agent Date
Section 4.
ALL INFORMATION MIDST 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 ize
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:
t
ity of Northampton
t l� uilding Department
' 212 Main Street
1 Nd'` 2 ant Room 100
{. No hampton, MA 01060
of Btsl�GsN�tt gl%S413- 87.1240 Fax 413.587-1272 =a e
DEP��T��yP50h.M.A 01060 � e =et;3
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1',- SITE;INFORMATION
Thts secttotito}becomple#edbyoffi�ce
4
1.1 Property Address: .�r
Y �sP�3 �� ��Ph k-_ ,�
Map h 11nt
Lot t
� s
Zone gONerlayDtstrtct
Elm St.District CB Ristrict
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1_Owner of Record: 1 r ;3 / [
W rint) x Current Ma�ing Addre � —6 Z
' '" Telephone 111 ��— `1'7 2 L( x I d
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION CC
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) Check Number
This Section For Official Use Only
Building Pernnit�Number: Date Issued:
Signature:
�pt�
Building,Con�missioner/Inspector of Buildings
� Qt cis°llT? BP-2002-0556
CIS# COMMONWEALTH OF MASSACHUSETTS
� CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002.0556
Project# JS-2002-0854
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 52272.00 Owner: WASLICK MARK W&SHERRI A&
Zoning: SR Applicant: WASLICK MARK W & SHERRI A &
AT. 1280 BURTS PIT RD
Applicant Address: Phone: Insurance:
1280 BURTS PIT RD (413) 586-6042 0
FLORENCEMA01062 ISSUED ON.•11129101 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER 1 EXISTING LAYER
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/29/01 0:00:00 1218 $25.00
212 Main Street,Phone(4 13)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo