24A-131 CITY OF NORTHAMPTON ,,
Construction r Affidavit -
in accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: d.--+ c2„,,,,8 £3C-
-- —The-debris will be transported by: S,) ,(2-S 6d 4g.,24 5i)E.
The debris will be received at: - , .1 4 e ,
Signature o Permit ppiicant Lll / �
Date 0 17�(J"
Building Permit Number:
k;
,
The Commonwealth of Massachusetts ,..A* rrri
Department of Industrial Accidents
i = l Office of Investigations
m 1 Congress Street, Suite 100,it
t :*
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): -(`r 1/lam i(,C '\ ( 5.-42,60 ��____ eidik
Address: 117- S, "" _�'�"
l`
City/State/Zip: �r0 I ! ilb hone #: Lilo 3 �� -
Are yoy an employer?Chj___ppropriate box: Type of project(required):
1.�i� IIaam a employer with 4• ❑ I am a general contractor and I
��� * have hired the sub-contractors 6. [' New construction
employees �iiii»D/o e).2.❑ I am a sole proprietor r listed on the attached sheet. 7. 111 Remodeling
shi and have no employees These sub-contractors have
p 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.
9. ❑ Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Ov f e...00c4 \ CD
Policy#or Self-ins. Lic. #: 515 11 „Z._ Expiration Date: (1/al /3
Job Site Address: tt City/State/Zip.. ) ai I I` MA-
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi nder t pai and penalties of perjury that the information provided above is true and correct
Signature: II I /,.._,._ .t Date:A oZ..,. ,1. ..,... 1
Phone#: 0-k 1'"1 - 'aD.Z i
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
•
1
)(A ) ()
,
•
SEC11ON 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
0 ('
Name of License Holder: `". I L am,/1 l L Q \ ' LY-1 3 I
License Nu ber
A re_ Expiration to
Sign- re T�skeptlone
L s or r�
=4
7.,r... . Not Applicable ❑
Company Name Registration Number
Address Expi atio�Date
i d 1�i Telepl on ectV "1 '
—
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 buildingjermit.
Signed Affidavit Attached Yes No ❑
The current ption for`homeowners"was,extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow s h homeowner to engage . 'F s ividual for hire who does not possess a license,provided that the owner acts
as supervisor. + i• 780, Sixth Ed • n Section 108.3.5.1.
Definition of H meowner:Pers.• s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended o be,a one • two family dwelling,attached or detached structures accessory to such use and!or farm
structures.A ye on wh onstructs more than one home in a two-year period shall not be considered a homeowner.
Such`homeowne" ; submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for . i itch work performed under the building permit.
As acting Con ton Supervisor your presence on the job site will be required from time to time,during and upon
completion . the .rk for which this permit is issued.
Also be : ised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to
Empl. ees for injuri-. not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
yo ire to perform • . k for you under this permit.
The undersigned"home wner"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 [ I Siding[ ] Other[ ]
Brief Description of Proposed
Work: �' i� f 5 1C��^J �0 { 1 „5��,(.. dk1P- W r,�,,�A��,��
Alteration of existing bedroom Yes No Adding new bedroom Yes No 904 5l,v"'J
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
earlf: if..tettah-and tw OR Eti #I illiU cemelefie,the;*11101A4013:
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. Masscheck 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
e0�/7Q [ / •as Owner of the subject
property
hereby authorize 1-iic..AA aCA 3jR4e—f\l^' i 5912 4 4
to act on my behalf in all ma rs -lative to work author' ed by this buil ing permit appli ation.
Sign re of Owner / Date
I= ,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.
Print Name
Signature of Owner/Agent Date
action 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 un by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage °lo
(Lot area minus bldg&pared
Pad ang)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/ '_•«-I Finding ever been issued for/on the site?
NO (DONT KNOW YES
IF YES date issued:
IF YES Was the permit re • de• - le Registry of Deeds?
NO DONT KNOW YES
IF YES enter Book Page and/or Document#
B, Does the si t e contain a brook, body of water or wet lands? DONT 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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES `'
IF YE describe size, type and location:
E. Will the construction activity disturb(clearing, • excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES C3
IF YES,then a Northampton Storm Water Management Permit from the DPW is required,
•ity'o#Northampton � ° ,� „��� ��,
=uiiding Department
20`3 212 Main Street y
Room 100
N. hampton, MA 01060 y
INSPECTIONS
DEPT.OF BUIIDING .'
MPTON mA.1060
NoRTHA • _587-1240 Fax 413-587-1272 �. � � tg w•
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This 1.1 Property Address: section to.be completed by office
a Pr . 4-10- Map Lot Unit
zone ,
-- Overlay District
Elm St..District CE District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
.1 Owner of Re ord:
�rre kith C��r% � � -
Name(Print) 5 Current Mailing Address:
/l S� Telephone
Si./ature
2.2 Authorized Agent:
KN'time(Print) Current Mailing Address.
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
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 Pertnit Fee
4. Mechanical(HVAC)
5, Fire Protection 1, (L // /y�
6. Total=(1 +2+3+4+5) { i
) 0 0 U Check Number ,/ 7 / / 3-5-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
27 PROSPECT AVE BP-2013-1212
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 131 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-2013-1212
Project# JS-2013-001984
Est.Cost: $14000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL KILLEEN 104311
Lot Size(sq.ft.): 7143.84 Owner: COURAGE GRETCHEN
Zoning:URA(100)/ Applicant: MICHAEL KILLEEN
AT: 27 PROSPECT AVE
Applicant Address: Phone: Insurance:
112 SUNDERLAND RD (413) 374-2027 WC
SOUTH DEERFIELDMA01373ISSUED ON:6/17/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 24 SQ 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 6/17/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner