32C-181 (2) 4.�ttAMPJ.O
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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE AF IAVIT
I, -
(licenseelpermittee}
with a principal place of business/residence at:
(phone#)
(s treei/ci ty/sta ffJzi p)
do hereby certify, under the pains and penalties of perjury, that
O I am an employer providing the following worker's compensation coverage for my
employees worlang 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/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyNolicy Number) (Expiration Date)
(attach additioasl iheef if noo=vuy to include iaf"Taitioa pertaining to all ooa radors)
( ) I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:plesae be aw2re that while homcownm who employ pczzom to do mt&uatca u�,coushsc too or repair work on a dwelling of
not moc'e than three unit+in which the homeowner r czidcs or oa the grounds appurtenant thactn are not gcoer2lty eomidacd to be
employes undcz the woritu's comps= tica Act(GL152,ss 1(5)),application by a homcowou for a 11-51-c1-permit may-id—the
leg2i rtntus of an employer under the Workeeg compo cation Act
I underhand that a copy of this datcmcat may be forwarded to tbo Dtparmsco2 of Indrutri d Aocid .&Off oo of luwr*oco for the-
age vaificatioa and that failure to swm covearga under section 25A of MGL 152 can read to the imposition of mminal penalises
comisting of a fine of up to 51,500.00 and/or imprison of tip to one year and civil pcnaltia is the form of a stop Worst Ord—"and a
Erne of S 100.00 1 day lgninA tnc-
Far dtpsrta� use°aly
Permit Nun"
Lot#
� � ignature of Li ermittce e
SECTION 8, ,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
c� 0 "fig 's` p,eme i#Contraction, " N, 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...... ❑
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,Stat and Local Zoning Laws and St to of Massachusetts General Laws Annotated.
meowner Signature
SECTION "i' DESCRIPTIONLOF PROPOSED WORK check all a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑
Accessory Bldg. 11 Demolition[] Sig s t ] cks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: '
Alteration of existing bedroom Yes_ No Adding new bedroom Yes _Z No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
6a, ff Piew{hoase ar or" addition 'existingAhausin Ofti a Ithe<<fol"to'�"vin�:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit:_ Number of Bathrooms L/
c. Is there a garage attached? A/ 0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? vZ-
f. Method of heating? G-4 S ;7VK N 19 S S 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 7i OWNER AUTHORIZATION -TOBE COMPLETED WHEN
OWNER5,AGENT O,R'CONTRACTOR APPLIES FOR=BUILDING PERMIT
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.
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.
Print Name
Signature Owner Agent Date
A
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
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:
ti
a
L VVit�f hampton
ui di artment °
12 Street
,i nn , E
AUG 1 3 vj R o0
Northam ton, MA 01060 e=s
once^413`=5 '1240 Fax 413.587-1272 0 s eM
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section tobe completed bWznp koffice
s �
!' 160 - 36a PLE
' Zone Overlay Distr ctm � � � _.
Elm:St. District CB District #
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
��.�1 F Da1:2� i . it/lLLg9b 346 Q
Name(Print) Current Mailing Address:
5--!R Y- 77 4 y
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item G 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) Check Number J�
This Section For Official Use Only
Building Permit Number: Date Issued:
§l" natu
re:
Building Commissioner/inspector'of Buildings Date
BP-2003-0164
GIS#: COMMONWEALTH OF MASSACHUSETTS
r2C tE: ` CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0164
Project ft JS-2003.0303
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. £t.): 18643.68 Owner: WILLARD HAROLD F&DORIS A
Zoning: GB Applicant: WILLARD HAROLD F & DORIS A
AT. 360 - 362 PLEASANT ST
Applicant Address: Phone: Insurance:
360 PLEASANT ST (413) 584-7344 ()
NORTHAMPTONMA01060 ISSUED ON:8114102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 3 PORCH ROOFS & BAY
WINDOW
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/14/02 0:00:00 2406 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo