12C-080 (9) 4THAMPT0
-
$ B �asaarflnsrtts'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ,
WORKER'S COMPENSATION INSURANCE AF+ AVIT
I �C� el
(li censer/perms tier)
witch a principal place of bugmess/residence at: >
ll a // �`�C��II ,� �b3s' (phone#) !�Y9 --5'7 7 �/
(street/city/ ap)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the folloNving worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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 Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insumce Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comp ay/Pohcy Numbryr) (Expiration Date)
(aaL di additional slicct ifnt,cz xry to inehsde iaform on P'tr i irs to ell oodrncton)
-( I am a sole proprietor and have no one wonting for me.
( ) I am a home owner performing all the work myself.
NOTE:plwse be aw-.un that while hon-,o-Ancra who crnploy puns to cio oxas7uaion cr rcpau work on a dwelling of
not nxee than thmo units in wiucft the homoowmcr resides a on the E Quads zpptsrtcnanf thacfo arc not Errxraily ooasiducd to be
employers under the worker's cear}xss cn Act(GL152.ss1(5)�appL ca6m by a homcown r for a license or pclmd may cvidcuce the
legal aahu of an omployor under the Workcet Compemation Act
I unacr t nd that a copy of this ctatcmcat may bo foawnnied to tho Dtpartnxat of Dial Ao6e,.,'oflioo of Lasv noe for the
covcrs g vaificadon and that failure to sure ooverngo under sccuou 25A of MGL 152 can lead to tho ins itiou of—road p-al -
oomisting of a fine of up to S1,500.00 and/or imptisonmeat of up to om year and civil pensltics in the form of a Stop Work OrdG and a
firm of 5100.00 a day t&&in5t mc.
r For dq,utmentnl tsso only
7 permit Number
�E l'`'L ��Z L �� .� Map t Lot 4
Y � Signature of Li ermitiee e
SECTION 8'-'CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /� Not Applicable ❑
Name of License Holder : /O M �G t-'/f'f /fit '� Cs Q S 3 1 o 1-7
License Number
Address Expiration Date
Signature Telephone
LARe` 'eedHom . . . - . . Not Applicable ❑
Company Name Registration N mber
11-5/de
Address Expiration Date
Telephone-5-'-/--/ —� 7 �y
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...... ❑
� � "M
11:x" ome ®caner AMU- 0
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(checkr-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: JTF,�/' �uc� f� •� k��j �"(�r �rw1 C) ref
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a `If"Neinr house and'or addition' o eitistine:h'ousing,sco ipletel'thel61,16wi"hk
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
OWNERS AGENT OR;CONTRACTOR APPLIES FOR BUILDING PERMIT
Oro a !] Q krcr n d as Owner of the subject property
hereby authorize Gi�1 ✓ „t lC1 -1 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Ow1kr Date
I,
O t" (yV� E1 / C{ki 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-e�^d under the pains and penalties of perjury.
!(�
Print
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 �f
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:
City of Northampton Sat F
Building DepartmentG
212 Main Street Se er
Room 100 It v a
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 P10 / tte
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This section to be completedAby office
t Z
M U rl . I T C I Map Lota Unit .
Zone Ouerlaypistr�ct
U ,
�_
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT :;]
2.1 Owner of Record: P,�}• �j C X 6 p.) C/
13 e< 4-�rct Ae MA 0c..
Name(Print) Curre t Mailing Addressl-
Telephone
Signature
2.2 Authorized Agent:
/ o l-o `1 IeA
Name(Print) Current Mailing Address:
t7' �� 5';,111 - S I/ rl
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed.by ermit 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) ' QCs a 19 C) Check Number p
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i I MARC CIR BP-2003-0796
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mav:Block: 12C-080 CdY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0796
Project# ]S-2003-1305
Est.Cost: $7000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Quinlan Builders 101707
Lot Size(sq.ft.): 11499.84 Owner: BERTRAND GEORGE&SHMLEY H
Zoning:URA Applicant: Quinlan Builders
AT: 11 MARC CIR
Applicant Address: Phone: Insurance:
5 Hillside Dr (413) 585-0949
HADLEYMA01035 ISSUED ON:3127103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & 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:Qh- 4f- 3el-d3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT-LON OF
ANY OF ITS RULES AND REGULATIONS.//-
Certificate of Occupanc /� Signature: (/
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 3/27/03 0:00:00 3507 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo