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DEPARTMENT OP DUILDr)\'G INSPECTIONS —,
212 Main Strect - Municipal Building
Northampton, Mass. OlOGO
WOfUCER'S COMPENSATION INSURANCE AFMAVIT
\vIth a piutcipal place of businesslresidence at:
(phone:') 603-Y3 6 7 S�
(st?cei/ tyk�clzli P)
do hereby certify, under the pains and penalties of perjury, .h.t
( ) I am an employer providing cite followint workers comoensZ:10,; cove mge (or Inv
etuplovees worUng on Oils job.
r (Insu.r•anc:z Coon: v) (PeLic; ?vu nirr) ;p rtior Date)
( ) I am a sole proprietor, general contractor or homeowner (ci:cie one) a-nd have hired
the contractors listed below who have the 'MoVllinp, worker's com�ensaaon pokiest
(Nnmc o.Coat cto ) (InRlr;tnc°. Comoa l)•01 o6cc, N un!Y;) (1->:air It:ott Datc)
(Name or Con(ractor) --- —Gwn urancc ComDanyfPoUc-�, N'tunirr) (Expo Lion Date)
(Name of Conaactor) (Insuranc: Compa-o)•/PoUcy Number) (Expurioo❑ Date)
(Name of Contractor) J(Insntranc-- Comcany/PoliCy Numlys) (L-xpa-adon Date)
(mach Udlitocal c'_uci if nccc:i.n to mcrudr inform.�oc pertn.inias to.11 ooa�-ac-o-�)
( ) I am a sole proprietor and have no one worlang for me.
O I atn.a home owner performing all the work myself.
NOTE:plc be as-uc tit,u1rJc Ht>o cmploy pcf o co 63 c •� c-m, a"Orx oo.d..cll_E of
a-mote than tt'-roc—u in ub the bocnoot'ocr wide o,co the U-D�aP�thce:n oa Ccact lay ocalid7cd w be
employers urx.'cr the v.ui u's oCIT�) tico Aci(GL152,,L5 1(5)�apptrca6oc by a homoo-oa for:bczr-=or po-MA r=y�i&Dcc the
Ieg et-t—of nn c ploys under ttso W or4_oe.Co¢cponvtioa Ae(_
I undcrvti d the a copy oft"ctsicascat auy bo for wnW to tbo Dcpartmcvt of l a-,c+id A,d&. 'Offioo of lrain000 for Lb-
covmsc Vrr&cuiOO std tttat U Mc to socurc'cova-.b tnadcr scc oo 25A of MGL 152 m Icsd to the Uz osilioa of crimiail pcn&Wcs
coosiu of a fiat of up to S 1,500.00 aadfcx itupri3.0 c of up to ooc yvr Emd civil P=Odm in 6,form of n stop Work Or'dcr nod a
fim of S 100.00.d_y tpaiost me
For dcp.rta�.=s1 u-oo)y
pt rmit Nu mbcr �-
/ map Lot
6
SIgi1.,l toil. oQlSC,Clhc mijacc
SEOT1ON S•C NSTRKTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 7yARRV T F �S 07—) y �L
License Number
Address Expi�n Da e
d0Y—
Signature Telephone
affifffflIMMIMMM,1W
... . Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION10-1t1ORKERS'COMPENSATION INSURANCE,A1"FIDAVIT(M.G.L.c. 152, §2550(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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
N = F PRQPOAE c I a li ab
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] 1 Siding[ ] Other [ ]
Brief Description of Proposed Work: 210-M V e- ,c LS�WI �ha �✓1('J R L D)AC e'_
Alteration of existing bedroom Yes_Al-No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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-„PWNER AUTHORIZATION,-TO;BE COMPLETED WHEN
QWNER ; GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
IJ� - h as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit applicat' n.
Signature of Owner ate
r z,,e Q 1A (,� 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 a d penalties of perjury.
Print Name / )
-j/2
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
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:
-
~
,
�
`
ity of Northampton
uilding Department
212 Main Street
Room 100
No thampton, MA 01060
tiFPT 5F BUILDING INSW 413 587-1240 Fax413-587-1272
NORTHAMPTON,MA 01
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I
1.1 Pro
---pgrty Address:
1A Q
PRO
2.1 Owner of Record:
Name(Print) Current Mailing Addrdss:
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Telephone
SignAture
S,E'01:10 IMCONSTRUCTION COSU
Item Estimated Cost(Dollars)to be Official,Use Only
compl ted by permit applicant
1. Building O.V 0.1r
(a) Building Permit Fee
2. Electrical (b) Estimated Total Cot't of
3. Plumbing Buildlinz Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
Date
Building ComAssion6i/InibOctor of Buildings
'
q BP-2001-0873
GIS#: COMMONWEALTH OF MASSACHUSETTS
.n CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2001-0873
Project# JS-2001-1605
Est.Cost:$6800.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HARRY FISK 072486
Lot Size(sq.ft.): 7797.24 Owner: WESTBURG CAROLE L
Zoning.URC Applicant: WESTBURG CAROLE L
AT: 118 HAWLEY ST
Applicant Address: Phone: Insurance:
118 HAWLEY ST
NORTHAMPTONMA01060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:REMOVE EXISTING ROOFING AND REPLACE
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 CITY OF NORTHA UPNW&ATMNDF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2156 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo