24D-098 (3) tX
The Commonwealth of Massachusetts
y _ ( Department of Industrial Accidents
fie . , g i : -; Office Ofllll/CSligBdODS
_3
k
600 Washington Street, 7`" Floor
Boston, Mass. 02111
t4 Workers Compensation Insurance Affidavit: Building /Plumbing/Electrical Contractors
Applicant information: Please 1'R11 T lily
name: Christopher H. Rice
address: 64 Butter Hill Road
city Pelha state: MA Z 01002 phone # 413 - 256 -3080
work site location (full address):
❑ I am a homeowner performing all work myself. Project Type: ❑ New Construction ❑Remodel
12 I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
❑ I am an employer providing workers' compensation for my employees working on this job.
company name:
address:
city: phone #:
insurance co. policy #
❑ I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone #:
insurance co. policy #
company name:
address:
city: phone #:
insurance co. policy #
Attach additional sheet if neee#
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certi , and the pains and penalties ' per ry that the information provided above is true and correct.
l e Willi Signature i t Date , ( 14.1 , 7/3
Print name Christopher H . Ri 3 ce aax���gqPhone # 413 - 256 -3080
,"d sr20d 1 't * ur .'�: a, ^t,'t' h . . ."d°'.r ta,?�,, **14 #iP Mtzt*M.. xA, w "".fm: .bFiret sR+s i'" fftt%' , k' °42 E'vs- !';has ✓ `o-`' F a:. i .+�i. S
official use only do not write in this area to be completed by city or town official
v
city or town: permit/license # ['Building Department ,_;
['Licensing Board
❑ check if immediate response is required ❑Selectmen's Office ro.
❑Health Department
contact perso phone #; ['Other ,'"
(revised Sept. 2003 )
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
eivr
N ame of License Holder : t `�' 'U � •
10M L,11-e-st f i VICI�.►' License umber p
Addr Expiration Date
l - ya-7 o ?3( 3if
Signa re Tel ne
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 ❑
11. - Home Owner Exemption
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 El
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Ea Siding [01 Other [01
Brief Description of P ose�L !J �O
Work: 1(L
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes t/ No
Attached Narrative Renovating unfinished basement Yes ,/ No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : Cane Family X Two Family Other
b. Number of rooms inteach family unit: Number of Bathroorns 1.5
c. Is there a garage atta NO
d. Proposed Square footag.,of • ew construction. Dimensions
e. Number of stories?
f. Method of heating? atu 11 Gas Fireplaces or Woodstoves No Number of each
g. Energy Conserv. ion Compliances Masscheck Energy Compliance form attached?
h. Type of cons uction
i. Is constru ion 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 .
1. 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
• vet. , as Owner of the subject
property
hereby authorize (.5 to P L-r +1--
to act • • - al matters relative ,• work authorized by this building permi application.
V 3 21 1
Si,,sf1 : Owner Date
I, ,i____,X a L , at__,i9 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.
Sign- • . -; - - - pains and penal ' s of perjury.
mila
' ame
10P _..--.1. ---1 3\ ?-1 13
Signatur- „ 0 er/ - . - t Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
�^� Building Department
Lot Size 11, Ua 1
- I _ I�.t v
Frontage ►" D
Setbacks Front
Side ) (
el
Rear
Building Height 1.5` °r,e -3 1/556,-.
Bldg. Square Footage. % 12-1
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: N`V"C Aft
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page, and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO C4 DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ,Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
RECE1V -o Department use only
' ity of Northampton Status bf Permit:
AMR uilding Department Curb Cut/Driveway Permit
'Z'6 2013 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
OEPI BUILDING 'NSPECTION. • rthampton, MA 01060 Two Sets of Structural Plans
• . "- : 1 `: " c- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
L APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
_5_7 , , 900 0 1 y 4 t a Map Lot Unit
0 (/ � �` Zone Overlay District
Or4 o/0 r3
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Debra L. Rice & Mark R. Welborn 57 Woodmont Rd., Northampton, MA 01060
Name (Prin Current Mailing Address: 413 - 835 -1925
;` i e -.�`` ■ �' Telephone
Signature _
2.2 Authorized Agent: + 11 D
l it`tr ■5 \ -v c e (n� 6 1 t �ik 1, ' - • 1 t ka Y ,�, ,n 0100
Name Print) bills Current Mailing Address:
413 L7 7
Si > !- Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com feted by permit applicant
1. Building k49.g57 O D (a) Building Permit Fee
2. Electrical Jg (b) Estimated Total Cost of
Construction from (6)
3. Plumbing ...9- Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection (� '-
6. Total = (1 + 2 + 3 + 4 + 5) s 11g5'?7, Check Number ? 1 3 �Fl 3 J
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
57 WOODMONT RD BP- 2013 -0870
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 098 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0870
Project # JS- 2013 - 001491
Est. Cost: $4850.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHRISTOPHER RICE 49847
Lot Size(sq. ft.): 11804.76 Owner: RICE DEBRA L & CHRISTOPHER H
Zoning: URB(100)/ Applicant: CHRISTOPHER RICE
AT: 57 WOODMONT RD
Applicant Address: Phone: Insurance:
64 BUTTER HILL RD (413) 256 -3080
PELHAMMA01002 ISSUED ON:3/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK :SHINGLE ROOF
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:
FeeType: Date Paid: Amount:
Building 3/26/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner