35-227 (2) � : �ausclituctti i
DEPARTMENT OF $UILDDyC INSPECTIONS
212*Main Street ' MunicipA•Building
Northampton, Mat s. 01060
WORI'CER'S COMPENSATION INSURANCE AFMA.VIT
with a principal place of business/residence at:
(phone#)
(str�tki tylstair./zi p)
do hereby certify, under the pains and penalties of perjury, chat:
am an employer providing the following workers compensation coverage for my
employers working oa this job:
(Lasu?ana Company) (PoliryNumbcr) (Exp fn do dD iu)
( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insuran=Compauy/Policy Number) (Fxpirmtion Datc)
(Name of Contractor) (Iruluantx Company/Policy Number) (Expiration Datc)
(Name of Contractor) (Insurance Company/PoGcy Number) (Expiration Dace)
(Name of Contractor) (Lnsurmm Compzay/Policy Number) (Expiration Datc)
(ana.ea s6&60ml sboee ifnooenary to 6dudc iafocmatioe pert:izang to all 000.7eGOn)
( ) I arri a sole proprietor and have no one working forme.
( ) X am a home owner performing all the work myself.
NOTE plcsae be aware that t+hiJo bomcowom wyo c�p(oy persocss to da a. + ooc sctioo or rcpa c work oo►dwCTMz of J
m4 mocv than tbroo ugiu is which the bomoownct resides of oa the tieuads Tpwut tbcMo ate Dot Caw.11y ooazidacd to be
employen uodcr tba wocktex pompea&4oa Ad ap Umsou by a homeowm fee a u—cc pm-aid may cvideme the
legal staaua*r&Q employe ued.t the W"kaes Compemaiioa Act•
I uaderN ad that a copy otthia t>stemmd may be tai+r+rd.d
to the Dep.stmc of otIoda+aAi.l A�idomtf t�iw of Isvunnw fa the
oo+^azgevcri$catioa taad that filuce to t:ocure oovcc>,to ta�det soctioa 2SAoCMOL 132 oa!ad W tbd imposiSoa eCetimind,pca►1$a
00osts6=g otst fie urup to s 1'500.00-&-impr60=XrA oCup to ooe yru Sad civil pernriia;a the form oCa stop Work or&r and a :1
fimQ(SL00.00&day rp!=Aw=
. FocdcpatEmoobttsaeeoty
permit Numbc r
)&p; Lot i
sic taf Li _ '
. crew
SECTION 8-CONSTRUCTION SERVICES
Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder J 63 I e j45
License Number
,dam
Address _ ' Expirati n Da
Signature Telephone
SAVE M- Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION_IN SURANCEAFFlDAVIT(M,G,L G. 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...... ❑
x .:
gym., €
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 buildinE 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
—CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [
/
Brief Description of Proposed Work: -5 ��' 9,r' 17 "�> g4/27 0y r J �'`1 05
Alteration of existing bedroom Yes No Ad//ding new be droom Yes No
Attached Narrative J Renovating unfinished basement Yes No
Plans Attached Roll Sheet
sa. If New house and'or addition"to existing housing. complete the following:.
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 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 be in all ma ters relative to work authorized by this bui ding permit application.
11
Signature of Own r Date
as Own�A�orized Agen
hereby declare that the statements and in ormation on th foregoing application are true and accurate, b-fMi_'-n o my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name _
Signature of Owner gent Date
Ala' rthampton
t .
BI.W digit epartment
2 3 12' Mafn Street
o rri� 100
orthampton, MA 01060
phone 41-3=587-1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: �Thrs sectiii to b ;rompletedby;affice'
Lyot Unit
zone iJverEaj(District
"Elm CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na e Print Current Mailing Add r ss:�
Telephone
Signature
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 ermit applicant
1. Ctr' (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 = (I + 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
58 LADYSLIPPER LANE BP-2000-1053
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block.-35-227 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category:roofing BUILDING PERMIT
Permit# BP-2000-1053
Project# JS-2000-1892
Est.Cost:$5400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Alan Shumway 103721
Lot Size(sq.8.): 32452.20 Owner: ZASHIN LYNN S&AMY P JACOBSON
Zoning: SR Applicant: Alan•Shumwav
AT. 58 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
625 EAST PLEASANT ST (413) 549-9658
Workers Compensation
AMHERSTMA01002 ISSUED ON:5123100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 5/23/00 0:00:00 2369 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo