29-041 (3) 0 0Tiv
R E Crii� cif 'lo tlialliploll
o DEPARTMEIJT OP DUILDp\,G INSPECTIONS —
0
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMTENSA'T'TON [NSURA-NCE A < < ANTI
(li ccnscx/permi UCC)
��dth a principal place of business/residence at:
(srl7c:�t/ci ty/state 12�P)
do hereby certify, under the pains and penalties of perjury, ?hal
( ) I am an employer providing the followinL workc�s comncns<aion cove age for nth
eluployces wortang on this job
(La%-r-=nom Cors=y) (I'eLic; Nu r) -- - ( ;pinion Date)
O I am a sole proprietor, general contractor or homeowner (circle oee) amd have hired
the contractors listed below who have the f000�vinQ worker's coonens tion policies:
(Naive of Contractor) (In umnc; Compa l)'/1 o N=C cr) (2.X71TdU0P. Date)
if
(Name of Contractor) -- (lnstranec Comaay/Polic-v Nu-»err) (Expl-,;lion Date)
(Name of Contractor) (Laa ance Compaoy/pouq- Number) (Expimoon Date)
(Name of Contractor) (I-nsuran Compatty/Policy Numbs) (L-xpiration Date)
(eaaGl]ad�i�ocal r'xd ifnc,c-iin to aKU�infornrition perrz.inin�to.11 peas-._r_o�)
( ) I am a sole propnetor and have no one worL-j-og for me
I am a home owner performing all the work myself.
NOTE:pl�be ew-uc t},,,H,-jc bocxx A"om wt>o employ peioai w do r, , ccv-r a c repair worm oa.d— ,g of
not more thr_n _L=?o in u41ich the twmoouver rtvde�oc oa the anunw4.3 zoputtc -tbern c.-c oo(Cv- ZIly oec:&rm to be
cutploym%I c L�'c—Q,i—I ccamp as-Lon Act(GLI52x=1(5) &pplic 6 n by n bomcowvcr fnr c lice or pcsmit r=y c.idmoc the
lcg:d ctn2u of en e5ployx under dw Wozkol,C.ocapomaLio AEC_
1 und--r d the a oopy of thii ctzrcmmt m„y bo fo.wnrded to tho Dcp�of tnd. jd 4nd nta Off o0 of I La.o-for th-
oovvnsc Vcrif C1loa and au-t L,i L c to soalfc oovcrrZc tmdcr scU oa 25A of MGL 152 can lad to ttx i q- s oa of aim n-11 pcairtia
000tismg of a Ctnc of up to S 1,500.00 and/or oCup to ott ye,f rnd aril pcnirLq W 6C form of n Stop WOr4 Order and a
rim oC S 100.00 i d,y t pja1t me
For d p nn, ur only
pCiZMt Numbcr
Si�natu
Nb PI of Lia riscclPcrriuucc e Lot y
CONSTRUCTIdN SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
MUM, �opg Not Applicable ❑
Comps XName ---� Registration Number
-
6-->
Address Expiration Date
Telephone
ECTIt�ri 1p„”woRKr�RS'"cO.MpEIVSl1TION"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.
igned 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
De
a
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ����`� O�►L° �Qy
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
ARMLEBAN
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
W g7Ia IQVT WGMeEt R GOAVf�TaR
„�ON ATi4N ;, c4MPLiro WHEN
R.A tR BUIIDNG PRM11TRAG
I 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
JK a as Owner o nzed Agen
hereby declare that the stat ments and information on the foregoing application are true and accurate, to the y
knowledge and belief.
011014igned under the pains and penalties of perjury.
Print Name
Signatw4rof Own gen 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?
v
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry Deeds?
V
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:
icy of� �rthampton
IdIhi epartment
� � t 15 1ZMarp Street
j Room 100
fib` Northampton, MA 01060
-587 1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S�"tf31V 1�`SlTE INF.t'�'t;;MAT10N
1.1 Property Address: r " '
C If ev-11, IRK
all
2
u saa
„ E ON 2-P OPE t7 Y O 1(INERSH,IPINUTTH k 11 D.AGENT
2.1 Owner of Recor
ame(Print) Currents'gy Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
$E STtAIIATED ONS IRUGT
Tl�f� - fON°COS F5
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Perrrrit.fe
2. Electrical (b) Estimated Total' ost of,
Construction fror (6)r
3. Plumbing Buillding,Permi'r Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) a Od CFfeck_f ;mber ~
his�Sect;lon"FrOfficial: tse:tl
Blatiding Perm t u'rnber: ae#e Issuerf�
Date
.
�il�ding Commissioner/inspector of Buildings
59 PIONEER KNOLLS BP-2001-0172
GIs#: COMMONWEALTH OF MASSACHUSETTS
.Iap:Block:29-041 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0172
Project# JS-2001-0283
Est.Cost: $2400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TODD BOYNTON 126807
Lot Size(sq. ft.): 11979.00 Owner: KAPITZKY JOHN E&PATRICIA R
Zoning:URA Applicant. TODD BOYNTON
AT. 59 PIONEER KNOLLS
Applicant Address: Phone: Insurance:
83 SILVER ST (413) 772-8829
GREENFIELDMA01301 ISSUED ON.8116100 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING 1 LAYER
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 8/16/00 0:00:00 1544 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo