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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ► Municipal Building
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE AF MA,VIT
(licenseeJpermi ttec)
with a principal place of business/residence at:
o�P a6Z1f St C' ' L/� (pi ones} V1 3 '-,::R96
(strr�t/ci ty/state/ri p)
do hereby certify, under the pains and penalties of perjury, that.
O I am an employer providing the following viorker's compensation coverage for my
employees working on this job:
(Insurance Company) (Polio Number) (Expiration Date)
( ) I ari a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaiiy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Comp'nly/Policy Numtx-r) (Expiration Date)
(Name of Contractor) (Insurance Compamy/Poky Number) (Expiration Date)
(attach adiiticc J Lhcct ifrccc vry to include infocmiIion pertaining to All C_Itmeor')
lin it sole proprietor and have no one working for me.
O I am a home owner performing all the work myself.
NOTE:ptcnac tx airarc that Nvhilo hcmcowncrs who anploy pczam to C�3 c.aintaJXnCr car G co Cr repair work on a&Nm ing of
not mote than thceo trait+in trhich the lwSxouver raidcs cr oa the pbu,-c s pp rtcn rd 1Lxscto r z oeX h'cncrally masidcrrd to be
employers under the%Yccka's o=pcnsaticn Act(GL152 X1(5)),npplicLion by a homeowner for a iiccrssc cc pclmit racy ct�daxe the
legal ctztua of an amployec under tin Woriccla Componsation A_
I uadcr: d that a oopy of this ctat.cmcat may be forwnrdi J to tho Dtv r�of Inhufrid A=dcn&Ofioo of In�uancc for thfl
covaagc vaification and that fail=to arcttre oovamgo undcx scctioa 25A of h{GL 152 can lead to d-imposition of cr mina!pcnaltica
oorniedag of a ftne'of up to S 1,300.00 and/or impriSo=Cnt of up to ow yzu and civil pcnaltia in the form of n Stop Woric Ord—_and a
firm of 5100.00 a day tgninst mc_
For dq utrucr tal use only
/ permit Number
p E Lot#
Signature of Liccnsee/Permittee We
� Ny
. �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SuDervisor: Not Applicable El
Name of License Holder C5 66 q 7S-��-,
License Number
Address Expiration Date
Signature Telephone
Wfir;i Not Applicable 0
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.
The current exemption for^homoowocm"was extended/oinclude pied f one(|) octwm(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.Homeowner: Person(s)who own a parcel of land on which resides or intends to reside,oo which there
Definition of 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 ii form acceptable to the Buildin- Official, that he/she shall be
responsible for all such work performed under the building permit.
&xwctmp-Construction Supervisor your presence oo the job site will bc required from time |n time, during and upon
completion of the work (cr which this permit isissued.
Also bx advised that with reference m Chapter \52 (Worker! Compensation) and Chapter |53 (ILiabi\dyo[Employers m
Employees for injuries not rcm|/iogin Death)o(the Massad`usnus Ocnoo\ Loos &nnomud, VOLI may be liable forpeoon(s)
you hire m perform work for You under this permit.
The undersioned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton On|inoncoo, State and Local Zoxino Laws and State of Massachusetts General Laws &xuma»od. ,
Homeowner Signature__�_ ___
`
�. '
SECTION 5=DESCRIPTION,OF'-PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors X
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] / Siding [ ] Other
/ [ ]
Brief Description of Proposed Work://t�S �f /��F�( rWZXI� �� 6,161 n[G. �}Me-s
Alteration of existing bedroom Yes__K No Adding new bedroom Yes NorN`w
Attached Narrative❑ Renovating unfinished basement Yes —4—No
Plans Attached Roll ❑ - Sheet❑
6a =If'New house and or audition o existing housing; cornplet"h'e:followin° :
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
L� as Owner of the subject property
hereby authorize f� { 14 _ — — ----- to ac` or
my behalf, in all matters to ive to work authorized by this building permit application.
V� -
Signatu o Owner Date _
MINIM
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 a e
S gnature of Owner%Agent Date _
i
e
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 X, 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:
City of Northampton 5 t sofP
ry Building Departmentu=
212 Main Street S
Room 100 a
Northampton, MA 01060
p-horve 413-587-1240 Fax 413.587-1272 Pto ite
AF'RLICAfi(Ohi•TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE 09 TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address: This s4.do o bed completed y;af ce f
�—� Byz4s �'y� Map Lot s 8 � t' unit
1
���� Zone �OirerlayD�strIct�
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Pri t) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Pr t Current Mailing Address
92 L113 --cA96 -VS
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. Elecirical (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 t
This Section For Official Use Only
Building Permit Number Date Issued: _
Signature`
Building Commissioner/Inspector of Buildings Date;
� f
584 BURTS PIT RD BP-2004-0480
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU-Block:29-485 A CITY OF NORTHAMPTON
Lot:-001
Permit But[O Q
Cate ory: BUILDING PERMIT
Permit# BP-2004-0480
Project# IS-2004-0684
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Pamela LeBeau 064756
Lot Size(sq. ft.): 30796.92 Owner: LAMPRON MELISSA J&
Zoning: SR Applicant: Pamela LeBeau
AT. 584 BURTS PIT RD
Applicant Address: Phone: Insurance:
248 Brvant St (413) 296-4506
CHESTERFIELDMA01012 ISSUED ON:10124103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS & DOORS
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: Receipt No: Date Paid: Check No: Amount:
Building 10/24/03 0:00:00 3441 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo