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r+,W �f_. DEPARTMENT OP BUILDING INSPECTIONS 4 SA E 1-
212 Main Street • Municipal Building
Northampton, Mass. 01060
WO 4 ' 'COMPENSATION INSURANCE ktelell)AVIT
I, 6 e-`,I7 0
(license&Jpermittee)
with a principal place of busine . resi ce at: ,
/.�! ,• % Y _ ! // " - � ' Dal`/
/c /,V e t/! rei ;s (p # ) 7 y /7/ :5
(street/city/state/zip)
do hereby certify, under the pains and penalties of perjury, that.
( ) 1 am an employer providing the following worker's compensation coverage for my
employees working on this job:
- (Insurance Company) (Policy Number) (Expiration Date)
( ) 1 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 Com ty/Policy Number) (Expiration Da te )
*r.
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyfPo icy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dace)
(attach additional short if necessary to include information pertaining to all contractors)
�a a sole proprietor and have no one w orking for me.
( ) 1 am a home owner performing all the work myself.
NO"T fi: please be mesa that vibilo homcowncra who employ persona to do maintenance, ooasanuzioe or Itpaa work- as a dwelling Of
not taco, than three units in which the homeowner resides or on the grounds appurtenant thereto arc not generally oocu durd to be
employers under the worker's compensation Act (GL152,ss 1(5)), application by a hotneowna fora license or permit may evidence the
legal status of an employer under the Worker's Compomation Act -
I understand that a copy of this etatemeat may be forwarded to the Department of Industrial Aoddmts' Office of Isnceance for the
coverage verification and that failure to secure coverngo under section 25A of MOL 152 can lead to the imposition of criminal pia ,
,,misting of a fine of up to S1,500.00 and/or • • of up to one year and civil penalties in the form of n Stop Work Or der and a -
fiUO of S �a mo. '
/ / ' //' ,/ For dcprztm use ontY /1(/`" �� Permit Number
�} t "�. j� Map;; Lot #
u t
---- . Si.. err of LiceascelPerrnitiee .
.
SECTION13 C 7NS,I Rt CTION SERVICES
8.1 Licensed Construction Sup r: -�'" Not Applicable ❑
�j �
Name of License Holder : c r:V 'E / //r r) i ,$
7) " 4/1 /4 1 ;e- -- /t/ r e 4,
License Number
dress / y Expiration D. e
'/' 7 . - G 775
Signa . re Telephone
Fle_i e ROrn a en ;per r A IM %� � ;` A , Not Applicable ❑
'411 HOF
Company Name ' % Registration Number
`'6 � 0 / / /:lYu/
Address f) Expiration Date
" /E' l C� ; Te I ep h o ne7 V 229 Q31f 42,9
SECTION10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. c. 152, § 25 C( 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 ❑
;: =o, wwneri , . �emption=
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
S C IO D R o PROPOSED YVOR -'Ehrlitatt.ba. ►licable �
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing=
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: I►e I 4 e . 4"& „..eferl
OF' Ex % c7
Alteration of existing bedroom Yes o Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes
Plans Attached Roll o - Sheet ❑
t a I f N ctithl and, or `additib -W O ei sfifitil 'o itili , coriip1 e16I16Vit g:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: N " bVf B t ropms
c. Is there a garage attached?
d. Proposed Square footage of new construction. / p 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
I, j�,a , as Owner of the subject property
hereby authorize R 4' to act on
my be If, in all matters relative to work authorized by this building permit application.
Signature of Owner Date L,'
� G
I, d as93sTCULauthorized Agent
hereby decl re that the state exits and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed und e s and penalties of .-
�!' ,/jam ,
Pri a e
Signa,t of ■ /Agent Date r ,
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) r '
# of Parking Spaces ,' //
I
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:
/V(1 e;tile
7e
4 �`5
City of Northampton
, ••• •- ent
L W 1 (j/ I i l ft: et - . o m �^ � € R� i 11/'IV Northarr� on, $ 1060
. on€0-1325 7c140 . A 13. 587 - 1272``
S pect �
APPLIC , TION QB9T +I n •� t l R, RE. AIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section tobe completed,byofftceF
L-C Map Lo 9 s nl ,
Zone Overlay District
Elni St:`District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
,rro —
Telephone
Signature
2.2 Authorized A:ent:
4001 ' - ,7 / s .0•0 o� o� ' i / - '/
Name (Print Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS - d
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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
Bi lldingPermit Number: Date Issued:-
Signature , ._. , ...
Buil" d, i* Oorrimissioner /Inspectorof _ Date „,
576 ELM ST BP- 2002 -0436
GIS #: COMMONWEALTH OF MASSACHUSETTS
$ p:llock: 23D - 197 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit # BP- 2002 -0436
Project # JS- 2002 -0664
Est. Cost: $2585.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq. ft.): 13503.60 Owner: ENOS GEORGE T
Zoning: URB Applicant: Robert Thibodo
AT: 576 ELM ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586 -0391
N O R T H A M P T O N M A 010 61 ISSUED O N :10 /2 4 /010:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE HOUSE ROOF OVER EXISTING 1
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 10/24/01 0:00:00 7998 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
City of Northampton
Massachusetts „, .�^a
x { DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Phone: (413) 587 -1239 • Chuck Miller
• Building Commissioner Fax: (413) 587 -1272 Assistant Commissioner
FAX THIS TO: 413 - 587 -1272
REQUEST FOR PERMISSION TO VIEW RECORDS
OR HAVE COPIES OF DOCUMENTS MADE
*PLEASE KEEP THESE DOCUMENTS IN CHRONOLOGICAL ORDER*
DATE: )�i MAP: 672‘ D B1 OCK: )97
FILE ADDRESS: 51 10 etfi
NAME: ` 0'1T
ADDRESS:
4 )1 ��, 9 r� P r
PHONE #: 11 - tg
UNDER MASS GENERAL LAWS WE HAVE THE RIGHT TO MEET THE
_ __ _ ABOVE REQUEST WITHIN TEN (10) DAYS OF THE ABOVE LISTED DATE.