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04cr> Of Nartflaill ton DEPARTMENT OF BUILDITjG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
(licenserJpermittee}
with a principal place of business/residence at:
S Q(W OUC SI L-��.� S (phone#)
(street/ci ty/sL a 1&2i 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:
(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) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Pok-y Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneaczssry to include information pertaining to all oowradvta)
.t� am a sole proprietor and have no one woriang for me.
( ) I am a home owner performing all the work myself.
NOTE:pl case be aware that whila homeoymen who employ pcmm to do maiate a acc�consuuctioa or repair work on a dwelling of
not more than throe units is which the bomaowncr resides or on the grounds apputtenard tb=w arc not gcomily wandered to be
employers under the worlc,a'a oxTeaseion Ad(GL152,ss 1(5)),application by a homeowner for a liccose or permit may evidenoe the
legzl status of an employer under the Worlreea Compensation Ace
I unda'Wnci that a oopy of this statemeat may be forwnrded to the Departmco2 of Iodustrinl Aoezd=&Qf .of k=rwce for the
coverage verification and that failure to secure coverage under section,25A of MGL 152 can lead to the imposition of criminal per Wlts
oomisting of a fine of up to S1,500.00 andlor imprison of up to one year and civil penalties is the form of a slop Work.Order and a
firm of S 100.00 a day agnimi me
For dal use only
Permit Number
Map# --Lot#
of Licensee/Permittee e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
:✓.�", ' .,:E &
' „._ .Nu. , ... .,. Not Applicable ❑
:E Yom,zz._ � .rLWfPdS I"S:.
Company Name Registration Number
//MC)GIfc- S 7110,1 e:) c;L,
Address Expir tion Date
Telephone 7-7/ 2 '
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....... ❑ 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
SECTION 5- DOCRIPTION OE PROPOSED WQRR(check all applicable)
New House ❑ Addition ❑ Replaceme t Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
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?
h. 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
1 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 Ow r/Author' ed Agen
hereby declare that the statements and information on the foregoing application are true and accurate, tooTF€
knowledge and belief.
Signed under the pains and penalties of perjury.
r�eJ �t 1 c�
Print Name
Sign of Own 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:
iCi rthampton
-g E�partment
2 ,aid Street
gU111!,UC,1NSpECZf off'100
pEt� ampton, MA 01060
ne 413.587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This
1q7_ � sec,ts i on f to,
llafCf�cr
1.1 Property Address: Mapi �l S �d
�
Zone O�rlay fllstrI A
y �
EttrSt }� +3 — -f= ffr9cM,e,.,.
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailin Address: �---
Telephone
Signature
2.2 Authorized Agent:
J yk O c.f e �
Name(Print) Current Mailing Address:
ature 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) Check Number
This Section For Official Use Only
Building Permit Number'.., Date Issued:
Signature:
Building Commissioner/Inspector of,Buiidings Date
a
1214 BURTS PIT RD BP-2001-0468
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:35- 191 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2001-0468
Project# JS-2001-0798
Est.Cost: $3350.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sg.ft.): 12196.80 Owner: REILLY JOHN V&VIRGINIA L
Zoning: SR Applicant. John Corbett
AT. 1214 BURTS PIT RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 584-5807
LEEDSMA01053 ISSUED ON:11 13100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/3/00 0:00:00 944 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo