29-374 (4) ti (rite Of �IcYZ tlTt�111�t,an s
J3ln Bit(hns(It 5 _
w I
..� nernlzTMt:rrr of tlurt-Dr>\c
212 Main St.rcct Municipal L.nilding,
Northampton, M11FS. 01060
WORKER'S COM-PENSATION INSURANCE AFFIDAVIT
(li�lLUrJ�-rmi tier}
with a plincipal plac.. of business./residenck� at
ST' ' 1z 444 C ldt�.0 (phone ')
(stzt/ci;y/5� 1C./2;p)
do lwi cbv certify, under the [),_ins and penalties of perjtlry
empiover providing the followinit �vorkel's colnnens:alon for in",
clllplovccs wol^:1118 on 1111s)oh
(r �1;anc-_ (Po11c� Nu_mtr_r
. ) Datr.)
1 ant a sole proprietor, genelirl contractor or homeov"mer (crcie one) and have hired
the contractors lisle-+ below who have the follo%Ving workerIs coT_1ncn_ation policies
(Nl,me of Co_. mclor; ([usuran(, Corupan}�Prlicr NumiY:) (F_�plr,tion Date)
(Name of contlac"Or) (Ilinlranc.. Coyne r n-ip0hcv Nutnr=r) (Expir pon Date)
--------—-
(Name of Contractor) (Insurance Compan)./Potlq' N urret) kExpimtlo,) Date)
('N'aine of Contractor) (In_siran(e Company/Policy Nurnikr) (Expiration Date)
(r.na.h additicx2il t_'uci if nc�rnar}to ak,ti,!-vzfin.tr;t�pci taic:ng to ell cxxr:rn r~o��)
( gun a sole proprietor and have no one working for me.
( ) 7 ain a home owner perfonning all the work myself.
CD
NOTE:plt sc be n—ut tlut wIulo hocnccr(vm wbo anpluy pc;unu W do axz�_r.»ion c rcc,w worx on t d-TILag oI
ncx nxorc duto Lm+e unit/in winch tfx ho N,_> ,jxr rrsido or(xt thr grounxb:ppurtensnt Ltettn n.-t ooe Ccnanity 000sidcrul W he
cr.,ploycra undo Lx wvricrti oxTciistion Acx(GLl52-"l(5)�nppLitation by n homcown7 fur c hccnsc or permit m--y cv#na the
legal
It-"of an omployoc under the Wori(oe,C«zxpomation Act
f undcrsi nd thst a copy of this t-L—mt rr y bo forwnrcind to tba Dc,[—tnmi of loduLvn j An do &Offroo of ln�for tho
—vaah-c vr"6cs1i00 and ttut L-M'c w scairc wvcmgc undcr section 25 A of hiQL 152 c.Imd W tba mp l oa ofcri i"pcailt-
comiriag of a fine of tip W S 1,50000 erallor=quiioc=xrA of up to ooc yrar and avil p®al',ia in the form of a Stop Work Order and.
f m of S 100.00 A dsy igauzl inc
For ckqirtnritil u.c only
Permit Number
T3i�:
SiE,iLthtrcofI.iccn_-( Pcrillittcc c -- ------
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone. 12e" ' > " r € Not Applicable 0 00 ems - ors 111,406 "q
Company Name Registration Number
-5--/S Zoo 2
Address Expiration Date
/v d�' j y��d/'✓ Telephone
ESECTION -WORKERS' COMPENSATION IN SURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))pensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
,ter ;t
11. .=Home Owner:Exemption
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 _--_--
t
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:COURA OUV—k Y I � <A1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative i Renovating unfinished basement Yes No
Plans Attached Roll❑ - Sheet❑
6a:If.New}'hous`eand or°ac�diti taezistin 'hoisi "="com Iete he'fbirowin":
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
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.
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 unde the pains and penalties of perjury.
riintt Name
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
a
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: —
.Y
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01062
phone 413.587.1240 Fax 413-587-1272 >~-
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section.to be completgd by office
1.1 Property Address:`
71 � )oXeW Map
Lots'
= ' C1nit
a
Zone Overlay,Qistr�cY
Eirr St. Distriit �CB.District'
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0— Wr4-4jo+ -
Na e(Print) Current Mailin Address
4 9 8�
Telephone
Signature
2.2 Authorized Agent:
&-/ 0 gd-e-�
Name(Print) Current Mailing Address
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted 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 = 0 + 2 + 3 +4 + 5)
�aG� Check Number
This
Gy,r Section For Official Use Only
Building Permit Number: �� ![ZJ _ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
171 FLORENCE RD
BP-2000-0996.
Gas#: COMMONWEALTH OF MASSACHUSETTS
Ma -Block:29-374 CITY OF NORTHAMPTON
Lot:-001
Building
qw
Category:roofing BUILDING P
Permit# BP-2000-0996
Project# JS-2000-1816
Est.Cost:$2500:00
Fee;$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: Licenser
Use Group: Ed Corbett Jr 116069
Lot Size(sg &): 13590 72 owner: IOLLEY CYNTHIA
Zoning:URA Applicant: E0 Corbett Jr
_
AT: 171 FLORENCE RD
Applicant Address: Phone: Insurance:
4 Reed Street (413)586-5192
NORTHAMPTONMA01060 ISSUED QN:519100 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER EXISTING 1 LAYER
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: Roughs House# Foundations
Final: Final:
Rough Frame:
Gas Fire DeQartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smo Final
.,
THIS'PERAUT MAY BE REVOKED BY THE CITY O ORTHAMPTON UPON VIOLATION F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Oceu anc
signature.
Fee Type: Receipt Na Date Paid: Check No: Amount;
Building 519/00 0:00:00 3525 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo