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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee}
with a principal place of business/residence at:
(phone#)
(street/city/stazrhip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
I am a sole proprietor, general contractor o. meown circle one) and have hired
the contractors listed below who have the following wor el's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
if if
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiom!shed ifneansuy to inchrde infamarion pauimng to all ooat n )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners wbo employ persons to do msinicuancq auction or repair work on a dweWng of
not more than three traits in which the homeowner rcudcs or on the grou k&apptutenant thereto are not gcaerauy coonder ed to be
e mploytra under the worker's oompcasation Act(GL152,ss 1(5)),application by a homeowner far a license or permit may evidcooe the
legal dubw of an employer underthe Worlra'e Compensation Ace.
I undusraad that a oopy of this su t-A may be feawarded to the Dopartmca2 of Indrutrial A=da&Offioe of Irmurwoe for the
ooverage verification and that failure to secure 00%vmgc under Seaton 25A of MGL 152 can lead to tba iazpasihoa of a=MAI pcn&W'cs
ootnisting of a fine of up to$1,500.00 and/or kgriso�of up to one ytar and Civil pemt ties in the form of a Stop Work Order and a
firm of s 100.00 a day against the
For dial u>o-tY
Permit Number
✓ Map# Lot#
SiPabire of Licensee/Pe ttee e
'
^
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder License Number
Address Expiration Date
Signature Telephone
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) L
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 ' fo«"6oneowuers'waxcztendedtoizobude one(1) or two(2)families
and to allow such homeowner to engage uoindividual
for hire who does not possess ulicense,
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 buildin Permite
As acting Construction Superviso 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 w-d State of Massachusetts General Laws Annotated.
Homeowner Signature I�u
SECTION 5 QESCBIPTIQN OF PROP OED WORK[check all aRRU9_Able)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. r)9 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
3 �Mkddjlft `
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?
In. 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 , as Owner of the subject property
hereby authorize (��� � �' to act on
my behalf, in all matters relative to work authorized by this building permit application.
A vt" -tC� y - 2s -ao
L
Signature of Owner Date
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.
V Q
Print Name
1 -2,5-00
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 ! '120
Bldg.Square Footage ' rl %
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: AX'001(.�?-�3
IF YES: Was the permit recorded at the Regis ry 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 k
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:
r
I, City'of Northampton
Building Department
$� 2 $ 2000 212 Main Street
Room 100
,.,,Northampton, MA 01060
'F phone 41681-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION A-SITE INFORMATION
1.1 Property Address:
this setfs t ► �ceplete �Of`e
AZI
S
��% M 1Cy
Eltxr-St ttstrlf "k
SECTION SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
4(/"
Name(Print) Current Mailing Adr 6.I�1
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SFC7lnIU . ESTIMATED CONSTRUCTION COST$
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 t coo (a)Building Permit Fee
2. Electrical (b) Estimated Total Cast 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
Building Permit Number: f f Date Issued:
Signature:
Building Commissioner/Inspector of Buildings hate
File#BP-2001-0333
APPLICANT/CONTACT PERSON KOPF SILAS W&LINDA M
ADDRESS/PHONE 18 STEARNS CT (413)586-6126 Q
PROPERTY LOCATION 18 STEARNS CT
MAP 38B PARCEL 134 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid a&7 Z=-
Tyueof Construction: ERECT 8 X 12 ARDEN SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildina Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THEY4LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservatio ommission Permit from CB Architecture Committee
d
Signature of Build' Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
18 STEARNS CT BP-2001-0333
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:38B- 134 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:shed BUILDING PERMIT
Permit# BP-2001-0333
Project# JS-2001-0546
Est.Cost:$3000.00
Fee: $25.0 0 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 8450.64 Owner: KOPF SIL AS W&LINDA M
Zoning:URB Applicant: KOPF SILAS W & LINDA M
AT: 18 STEARNS CT
Applicant Address: Phone: Insurance:
18 STEARNS CT (413) 586-6126 (1
NORTHAMPTONMA01060 ISSUED ON:10 16100 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 8 X 12 GARDEN SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House`# Foundation: ;
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHA 'ITON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS./
Certificate of Occu - si nature:anc _
Fee-Type: Receipt No: Date Paid: Check No: Amount:
Building 10/6/00 0:00:00 264 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo