29-145 (2) -
4TtP'o
goo °$ �2 Df wart11aIIlpfult ^
- �aEbaClltibfllE
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A'FMAVIT
(licensee/perLnittec)
with a principal place of business/residence at:
/,�._y truer)/':,j. !''1 �' F'ff/='✓ r!"`1' .fit ;rf,/',`> �!% (phone#)
—� — (street/city/statehip) i'9 (,
do hereby certify, under the pains and penalties of pequry, that.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Gastuance Company) (Policy Number) (F---,,,pim Go n 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)
.f
(Name of Contractor) (lasurance Company/PoLcy Number) (Expiration Date)
(Name of Contractor) (lnsuraacc Compan y/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioasl Shed if mcctvry to iochsdc iafo maIIon ptrtaiuiug to all ccc ractors)
( ) I a1n a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please be a Ar that while homeow'txra who employ pazo to d)traiotcnancc, oa or repair Hv is on a dwelling of
not moce this throe units in tcftich the hocmo"v resides or oa the ad-appurtcnaxij thucto arc no(Etna-ally comidcrtd to be
cm IOYcrs 1113dcr the work&s coaq cessation Act(GL152—�s 1(5)),application by n hotncowna for a 6ccnsc cc permd may cvidmoc the
legal elaius of an employot under d-Wocicore Compomatioa Act
I undi z d that a copy of this rlatcmcut may ba foawardad to tho Dcparfmas2 of Industrial Aoadc a&Offioe of L---oe for the
coverage verification and that failure to secure coverago under soctiou 25A of MGL 152 can Iced to the imposition of crimia+l penalties
eonsistiag of a fine of uP to S1,500-00 and/or imlxisoarxxnt of up to ent year and civil penalties in the form of a Stop Work Ocdtr and a
faro of:S 100.00 a day tg&insi mG
For depastnrntal coo oily
permit Number
Lot#
619nadlre of Lic=scc/permittee
SE#GT ON I8 fiC6NSTRUCTION,SERVICES �
f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
.T o mp o erenAC*o ctr Not Applicable ❑, ,
Company Name Registration Number
Address Expiration Date
Telephone
SECTION-10-WO.RKERS':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 affid
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)familie
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 �n,�,r:�!� ��� !_..•-�"��-�z_�'* �'f ,_�
gl
)) EC pIONj 'DESRPaOl IOF PROPOSEb H ORKhycciial a lic`able
WIN:!.., •1 'RS' .,.r,"' ,3..;a- i.�+. 3il�h �; 31,v.:`.;a.. :..w .^.;,ea ,.N.k.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ TRoofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
7 r
Brief Descript' n of Proposed Work: sh �_ _ ';; ,* ,� r.a> .` , " ' .�; `, ° X-,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
"r. `° d(J-d oJw dition.to a casting ho sung,.corri'pl:e l&th"" .4611dwine:
awIfi N'eW hot' Ee
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 =TO BE COMPLETED WHEN
OWNERSAGE[`IT OR CONTRACTOR°APPI:IES OR: UILD)NG PERMIT
as Owner of the subject prope,:
hereby authorize to ac
my behalf, in all matters relative to wor authorized by this building permit application.
"�Signat6rener 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 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 ize
Fr nta e
Stacks 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 u— 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:
p
City of Northampton
Building Department r.
212 Main Street e e
Room 100 er.
Northampton, MA 01060 � ots q
phone 413-587-1240 Fax 413-587.1272 otlS�te.P a
Ot er Speoi ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
peted by offiThis m cea
1.1 Property Address: `
r
f� Map Lot ^ Unit
�- Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t! C-'+L.•/1�' �'l �,� � �i� �i.�,f'� .F G.r�/( �f..i,,i! .ate {:`./X.�'�°'' .i sue'�".T.�..�- !3 .r E r ,.
Name(Print) .� Current Mailing Address:
Z —
,.Z.�. Telephone
Sign ure
2.2 Authorized Agent:
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 = (I + 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-2002-0196
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Buildlnq
Category:roofing BUILDING PERMIT
Permit# BP-2002-0196
Proiect# JS-2002-0312
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 43995.60 Owner: SCHNEIDER KENNETH A&ELIZABET
Zoning:URA Applicant: SCHNEIDER KENNETH A & ELIZABET
AT: 70 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
70 SPRUCE HILL AVE (413) 586-0487 ()
FLORENCEMA01062 ISSUED ON:81211010:00:00
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: 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 8/21/010:00:00 1718 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo