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DEPARTMIENT Ot' PUItDI;�G INSPECTIONS —
212 Alain Street ' Municipal 73tfiUni,
Northampton, NASS. 0110
WORTC R'S OWENT SATION iNSURANCY, AFFMAVIT
1 w
Wh a principal place of businesdresidence at
---
do hereby celid , III ur the pa!i)S and penaltit-� Oi jiCrpny, UhI
I x111 all employer provlding the Wo"In I)`.r&5 t`I ply
employees working on t�lis job:
(Insur-�uIG; Cna�n}') ( t ic-,Numtre (Ex;:�rauon Date
O I ant a sole proprietor, one) and have hired
the contractors listed below %vho have the "",Oo kel's comp r.sa:ion
-- aymne of Conirwol —Onsumnuc COn 'Ii 1Cy Tvlllilr• r) - (I.x: ::at!On tea tC-
(Name of Comaclor) IZILSIIMn COOL . �iPt!1Ct' Nl!I17L i� ���, i •.t10n Date)
(Name of Contractor) ,,.t:__.hate)
------------------------—
(Name of Consactor) (Insurattcc Comat�y/Tolicy Numbs) Ezpil.:iiol:Date)
11111 it ;;Olc ;)loplictol ai1Q hav(' no One: Ikmg for me.
I dill �! hom.'e ow!),C: p,'!fo,-Inin all tli�:
NOTF-:p(C�sc be ,wa-:C that
not:ncrc t}--n dr no un,+ in��{_i�t the I..ra ur z rear ct cxt L` - .s z^;urtr,lilt 11x-CtO
cmploy��under tl�c wc;kci cc; csatim i d((J I_I52--s 1(5)), 1, s ha iman r for e Lccr ct lrr;u: nr is
legal AM;of an omployx under oo OWN.C,txu;raraltipct Ac(-
I undc.-itt d that a CQ y of t}u>,ci>ta:m2 2tay ba fo,,--ded to tip[)cS—t::rtit of Incti>_at,id A,66�f e Off—of I:::iu u>-e for tlm
mvezigc vCrificalioo and Out failure to r-atrC 001,1mgo ut:lcr c^25A of tGL 152 can[C-.d to tl c im ositia u;c ^.i l pttult:cs
--)Misting of a Eric ofup to S 1,500.00 att.'or in:prixxLrr_n1 of up to n•)-u raj Civil pciultia in dr form of n Step VYCI�-Ord-: and a
fits ofSIN.0(l a dsy fg}iu,t m-.
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SECTION 8e-CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Appllicaab'le El
Name of License Holder :��/✓y �� ���1 (., L-' 3e
License Number
r���
Address 2 xpirati n Date
Signature Telephone
Not Applicable ❑
�Regi�te ed H'�mmprovement-Contractors �, ��.. _. �„E�;:..
Company Name a Registration Number
2Z`1' C/v r�k 1 � s�l02� z Q
Address J Expiration Da e
Telephone-
,S �Z-
ECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NI.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 fe which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 15') (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 _
S
CT 6� �33I �I O PROPO ED WORK(check all applicable)
SEIONS �DESCRIPT�ION3t
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ ]
Brief Description of Proposed Work: ' � &Z (
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a` If.�New h�oase a'�i"d fir"• a�ddition4ao�exi"s"ting<ho'using comphe�e the�fol ,ow:n�:
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 _ _ i,Io. Is construction within 100 yr. floodplain _Ye_;
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 A OWNER AUTHORIZATION''-TO BE COMPLETED WHEN
OWN.ERS'AGENT�QR CONTRACTOR;APPLIES FOR BUILDING PERMIT
l as Owner of the subject property
hereby authorize � ��/� J�' � UU 1 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/.Author d Age^n
hereby declare that the statements and information on the foregoing application are true and accurate, to the best o
knowledge and belief.
Signed under the pains and penalties of perjury.
Prin , ame
Signature of Owner gen 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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IFYES, describe size, type and location:
.w
ty of Northampton
(� ilding Department
12 Main Street
Q Room 100 W r/1Ne
mpton, MA 01060 . eso re;
(5honP 41 58 1240 Fax 413-587-1272 Flo /SlteMall,
�S c?� r Sped
L0111 RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro ert Address: This'sectlortto be completeby.pffice
p �' A �
s �Ell
r
�— .Map Lot r« Uni
l� Zone Overlay District�
Elm St. DistrictCB Dis#rict
SECTION,- - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Prigt)'� Current Mailing Addre s:
Telephone
gnature �3
2.2 Authorized Agent:
2'&t 5�f(v Vii `
Name(Pri t) Current Mailing Address: l� ot,
l.J
Signatl re 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) stimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) t Check Number
This Section For Official Use Only
Building;Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
.z l :. BP-2004-0212
GIS#: COMMONWEALTH OF MASSACHUSETTS
X53 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0212
Project# IS-2004-0311
Est. Cost: $1560.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: DE Sheppard Roofing 105885
Lot Size(sg.ft.): 6751.80 Owner: DUVAL PAUL H
Zoning URC Applicant: DE Sheppard Roofing
AT. 11 HANCOCK ST
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092-0
CUMMINGTONMA01026 ISSUED ON:8125103 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP FRONT PORCH ROOF & INSTALL MOD BIT
RUBBER 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 Occupangy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/25/03 0:00:00 754 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo