23D-018 (2) �tt1/W p�O
�[3EAChttSCItE'
DEPARTMENT OF BUILDING INSPECTIONS '
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
�; (lltxnseeJpermlttee)
with a principal place of business/residence at:
Af—
� ( city/stalrJap)
do hereby certify, under the pains and penalties of perjury, that:
(W)/I/am an employer providing the follotiving worker's compensation coverage for my
employees working on this job:
i� 2 / a 10 11/r4 3 &,-'. 1''3fS' �?r,(�rf` �I`�1i� jJ •� 0�
(La!s ancc 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) (Expimtion Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/pohcy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Po1icy Number) (Expiration Date)
(attach additional shed ifntccssa to include infornuhon perta wing to all ocalrncion)
( ) 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 wililo homcoKVcn who employ poll r to cio maint�0xr3t-action or repair work oo a dwelling of
not nose than throe units in which tilt homoow acr raids or oa the Ern,n xppartenwlt thereto ere rx,(&aaaally oocaidcrtd to be
employers under tho worms a0mpcnSation Act(GL152,s3 1(5)�aWicatioo by e homcowacr for a lions=oe permit may evidence the
legal status of an employer under the Woriceee Compemation ALL
I understand thi2 a oopy of this rtatcmnat may bo forwurdod to tbo l taxat of Indust d Amid.&Offioa of lr,% co for tho
oovaage verification and that failum to socure ooverago under scetioa 25A of MOIL 152 can lead to the imposition of criminal penalties
ooasisUn of a fine of up to S1,500.00 nndloe imprisosmxut of up to one year and civil pcnaltia in the form of a Stop Work Ord--and a
fins of S 100.00 a day agniwd mG
For dgrutrne W vao colt'
� permit Number
�{ Lot#
-
SignaWm of Lio=-,.wJpermi ftee Y e
�' t ��C
SECTQN8 Ci7N5TRUCTI�N 5ERVIC`ES i ,:
x
8 1 Licensed Construction Supervisor: y Not Applicable ❑
Name of License Holder: <,y j x'
r License Number
Address / Expiration Date �y
Signature f Telephone
m =mar
ve Wh n r ' r� V :� � ,' Not Applicable ❑
Company Name Registration Number
6 / fir, /-?0 '�r� /C`- -.r, , :/
Address / Expiration Date
, ?/_ 7�,�1 r�, r y,.r �`✓� Telephone
SECTION 10-WO.RKERS';CQMPENSATION INSURANCE AFFIDAVIT'(M.G.L. c. 152, § 25C(6))_
Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affid&.
will result in the denial of the issuance oy the building permit.
L.Signecl Affidavit Attached Yes....... Li No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familic
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(
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�ar, p3� 'ii°= r
SECTfON "i DESCRIPTIM Q PROPOSE>i iNOR _shack al a licable � � �
w 33 w 3§N w. s a�a�+sa»ximw�.a 3 r sxinw z �-a 11��q H
>
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ 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 ❑- Sheet❑
sa�`�1fNe'w�ho�se an°"�ior �dtlit orito'ex'rst�n"" fio'usin;=,�co'mpletethe-�follo"u' II"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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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 TO3BE COMPLETED WHEN
011VNERS AGENT;-OR*CONTIZACTOR APPI.IE510„R,NBl11LDING PERMIT
ca /° - as Owner of the subject proper
hereby ' �, ti 's _- �? ' to ac
my behalf,jfr all m ers relative to wor a D46clyy this building permit application.
Signa u of ner Date '
aver/Authorized Agent
hereby declare that the statements and informa ion 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
0
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:
tl u rthampton S
Q Build g epartment Curb
200121 n Street or ,
AUK 00 100
pto , MAO 1060 T#wo Setif .r c, a
1240 Fax 413-587-1272 F?Iot/SIte�Piat�s
NORTNA� therSpec�fy
4;.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 - SITE INFORMATION
-This section to be completed by office .
1.1 Property Address:
Lot' nat
v
Z
laP A rr �5 4,4 F
O
^� L: one verlay District y-
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:;
�1 ✓� Arlo
Name(P Curre Mailing Address:
Telephon
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Ad ess f
( f.
Signature Telephone
SECTION:3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building cl�r' -- (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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: -
Building Commissioner/Inspector of Buildings Date
. BP-2002-0187
GIS#: COMMONWEALTH OF MASSACHUSETTS
h 4
pt ;b CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:vinyl sidin BUILDING PERMIT
Permit# BP-2002-0187
Project# JS-2002-0291
Est.Cost: $3820.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sg.ft.): 7100.28 Owner: MCKEEVER CHRISTOPHER J
Zoning:URB Applicant. B & R Siding
AT: 540 ELM ST
Applicant Address: Phone: Insurance:
781 Bridize Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:8116101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/16/010:00:00 17806 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo