32A-195 (3) r
4�1 PT0
s a Crif� iaf z#Elttnt� nit
� B �aiaacflnsrtta
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WOMCER'S COMPENSATION INSURANCE AFMAVIT _
(licenser/perm ttec>
with a principal place of business/residence at: CY t66
110, L�Ua�C.. `�r � kc—i �ANP—Iek'-
(grMUcity/staW2iP)
do hereby certify, under the pains and penalties of perjury, that
(vf I am an employer providing the following -worker's compensation coverage for my
employees working on this job:
I p 0 u�L 4,V CC) �CU C &OL {ter d cry 2. v•�
(Insurance Company) (Policy Number) T- piration ate)
O 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 Corupany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparty/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(attach Additional short ifrntcrc u to inc} information prxtaiuing to all oa¢tredots)
( ) I am a sole proprietor and have no one worlLing for me.
( ) X am a home owner performing all the work myself.
NOTE:please be aware that while hemcow-D=who employ pco;cm to do mamt�o*,C!x .ion ar repair worst on a dwtlting of
not more than then units in which the homeowner rezid,=or on the gcound3 appurtenant the tto arc not gcna-.dly aoe idcrrd to be
employers under the worm ccmpcns cn Act(GL152,z 1(5)),application by a homeowva for a[1=3c or permit may evidcaeo the
legal statua of an employer under the w"koea companseion Act.
I understand that a copy of this ctntcmcnt may ba forwarded to tbo Dcputacal of Induitrial Ac6&a&of co of ln—')O for the
coverage vaificatioa and that failure to scarce coverago under scctioa 25A of MGL 152 can lead to the impwudon cf a=m-ll lxnalt:es
ooqustx: g of a fine of up to S1,500.00 and/or imprisonmcal of up to otx year and civil pcmalti a in the form Of.Stop worst Ord--and a . '.
fine 015100.00 a day tgainst mr-
4 For deputm�l use O°ly
permit Number
(` 0 /f Map# Lot#
SiPaturc of Liccnse ,rmitt,-
SECTION 8-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ,�(o�-(
License Number J
N + -3 lie
Addres Expi— r Dat
Signature Telephone
. �9 ` ` t K k F NNEe.
. . ..ten.k Not Applicable Iicable ❑
OAUiI 1-00 /,UIC,Ag1z T a4 G 4.PU� tS /L) Cq`I
Company Name Registration Number
� IttUKt -L '! , ti
Address ExpiratioA Dat
Telephone � ��
SECTION 10-WORKERS' COMPENSATION IN 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 the building permit.
Signed Affidavit Attached Yes....... qr No...... ❑
,M
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-'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: ' S LCi ( & )( I1 C fAJ CJ S D1 fa
OvR�- �,�csti�4
Alteration of existing bedroom Yes No Adding new bedroom Yes No A C�6 S
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑ G ELI LA V"
6a°Ifi New`liouse��andror"�addit`ion.to ezis"ttng=f1`ousin`g,�complete�.thefollowinir:
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
OWNER'AGENT dR�CONTR"ACTOR,APPLIES'FOR BUILDING PERMIT
1 y,Z as Owner of the subject property
hereby authorize / v' vf �� H "� `� to act on
my b If in all matters relativ rk authorized by this building permit application. 'f
Si ure of OwnerVr Date
U ( ,P U ° '� y`,r 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.
F z� ���� s ��� � s Lie.
Print Name
xRU /it Ut-
Signature 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: 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:
-- y of Northampton
Hding Department C u
12 Main Street .
Room 100
mpton, MA 01060 T is
phone 41 -58 -1240 Fax 413-587.1272
,�-.......----_'°'"....-. •DNS �th�eisSp �l�yf ". . � �� °.
rAR-itc,At t � nv TRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This.sectlon,to be completed by office
1.1 PrODertv Address:
Ma 3 �Lot � 111#
�' 4 P
Zor1e erlay»Distr ct
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam r t) Current Mailing Address:
Xu Telephone
S °ature
2.2 Authorized Agent:
ol'l X441 W44tyyU' '?, L �40o_ f2 L 7 ��`���f�l�t�'rc�c
Name(Pri 1NZ i Current Mailing Address:
�
� —75 L
�
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by ermit applicant
1. Building r� ��J v E (a) Building Permit Fee
l r
2. Electrical (b) Estimated Total Cost of
u Construction from 6
3. Plumbing Building Permit fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) 1 q'i0. J 0 Check Number z671
This Section For Official Use Only
Building Permit Number: ]PI)ca-- - 019 Date Issued:
Signature:'
Building Commissioner/Inspector of Buildings Date
File#BP-2002-1105
APPLICANT/CONTACT PERSON David Fortier
ADDRESS/PHONE 32 Laurel St (413) 586-8965
PROPERTY LOCATION 24 PHILLIPS PL
MAP 32A PARCEL 195 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: SHEETROCK OVER EXISTING WALLS&CEILINGS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FO�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFVRMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street C ssion
Signature of Building Official Dat
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Wow
24 PHILLIPS PL BP-2002-1105
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32A- 195 CITY OF NORTHAMPTON
Lot: -001
Permit: B u l l d i n a
Category: BUILDING PERMIT
Permit# BP-2002.1105
Project# JS-2002-1769
Est. Cost: $18400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: David Fortier 008026
Lot Size(sq.ft.): 7884.36 Oiviter: FLYNN CHRISTOPHER T&AISJAH T
Zoning: URC Applicant: David Fortier
AT-_24 PH!'.1 lPc P1
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965
NORTHAMPTON MAO 1060 ISSUED ON:6112102 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK OVER EXISTING WALLS &
CEILINGS
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: (Q l-2S/U House# Foundation:
7 Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Ir:uft-fl-n:
"""--rarat. Smoke:
Finn •,.
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy --
_ Si�na.are� _
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/12/02 0:00:00 1071 $25.00
212 Main Street,Phone(41 3)587-1240,Fax: (413)5$7-1272
Building Commissioner-Anthony PatOln