32C-294 (7) lg�
r 0 Nis
EOYE C-VV-`"ER E-N-O W- DGE-NEN.
T
I Tire SLa:aO:FM-2ss--ChLS,-= a!-Tows ho r"IgIri. under 780C.-Na 108.3.-"r to
I -— -, . - , *or -: - '•': ,, - - e- -;4�� -- - -7,a -
.Le,-Cons -Lcz , 5, --
T es �-TomecWne, -E, so, 5
Clt,L C-L 1"-
a -n'L or twofa--.-]E�7
on wliic' e resid,es or L -end-,to be, a-Orze .
or&-acLled- accessor a - 5=
Y to sucl us-- and1cr
person-wL.c ccrstru=more t l czehome in sLaJT not be considered a
home oF1ner.-
T-f-d bUEldiM£=e-eEiEF-..=L-,eT f.-F the C I%v 01. - th 12 Wants =17 ye.'Wr_(S)-who Seek to
=d the home-C-'Wmer ex=Loz, to a-- as their Ow.-I CZMISU—U,Wt SUpen'.5—,
that b-,7 do—Ir-z- so v-or- become r--sDQnS;
iblc for compIlin-ce with state buBdinz codes
and reTja:-t'c=- The proces-s-re-i— tLal the buElding de-p.-r=ent be=Jled
to insrect wcIj—'r at rious 5-,ages, which include found2tionffootings(before b2cIdUl).
sonotube holes (Before oour). a rough buildin-g:husmediorr(before work is
(ff re-zuLT-ed) The
bui2ding dep=e=requ-Tes tLes.-inspectons before the-work is ccrcealed, f2fure to
Secure tHese i=,jections can result fn failure to obtain a cerd5cate of OCCUI)ancv
Z e h. e 0 other trades ex(ellec=
7-7—ner MreS 0 pe:70rm wo plLmbing L-Has) the
le to r-jal- proper
-WEIT be ----4 se----e tHeir
-Zes hL,7
CtjOn tO the bL-T Ll dia Z- p e=, t their required
i=-d" and that thffv
=pectiors-FaHlure cl"the Ldlivid7 T--I tra-Z,es to secuye the pe,=H-S and=ZT:error as
�_T,A an 72sp ctions are
re ed can D-li-?.AY the projit-I u=-J such tie as the properpern-mits d e-
mad e
derstand the above_
(mac m,e.-OWU,-rAeSid-e:ne5 SigMature requesting exemption)
I,W�27 ca2-7 to szLedul,-all required building mspector-s necessary for the bLiIding pe=it
iss-ued
Date
Aciri:-FtsS OF vin
Office of Inves2gations
_ 600 t;a man;ton Strut
Boston, !I1-4 02111
3A•'1t%W.1r.ass.;ovidia
Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/PIL�mbers
A rcu leant information Please Print LeEibiv
Name (Business/Or2anizanon/Individual):
City/State/Zip: �,,, Phone #: j��—`1 7)
e, �'ou an employer? Check the appropriate box: Type of project(required):
I l.I I am a employer-wah =I• ❑ I am a general contractor and I
6. construction
employees (full and/or part-time).T have hired the sub-contractors
❑ New
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in ary capacity. employees and have workers' 9 (❑ Building addition
[No worlcers' comp. insurance comp. insurance.--
re fired. 6. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
qu oaicers have exercised their 1 l.❑ PIumbin-repairs or additions
I am a homeowner doing all work
myself_ [ 'o worlcers' comp. right of exemption per YIGL 12.L/J Ro4frepairs
insurance required.) ' c. 152; §1(4), and we have no
employees. [No workers' li.❑ Other
comp. insurance required.]
`Ana applicant that checks box:T 1 must also fill out the section below showing their workers'compensation poiicy information_
Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information. ,
Insurance Company Name: ''S � � � � 4 G,,
Policy, or Self-ins. Lic. �: 3 Expiration Date: 3 3 6
Job Site Address: yc City/State/Zip: N S
Attach a copy of the workers^ compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI_A for insurance coverage verification.
I do hereby Gerd urrde;th�arrdentteerer}acfya the information provided above is true and correct
S i--nature' -- � �a Date:
Pl cne_. L.' �
__. ffzcr irzL.zz�e-_r zh,__D_.at_•rit�lhis_ttr_ett�to &e cam city or town o ciaL
Ci v or Town: Permit/License r ---_
i lssuin2 Authority (circle one). j
i. Board of He2lth _. Bu"tidn_ Department I City/T owru Cle-1- 1.Electrical lnspector _. ?!UM` ? Inspector !I
6. Other
Cvnt i t �erSJr: Phone
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
S (;
Name of License Holder: \"i ry� �l D � � C C7 "I
License Number
C4 CL
Address 1 l Expiration Date
Signature Telephone
S.Reg>istered'Home Improvem Co
ent ntractor:„, Not Applicable ❑
n
Company Name l tl Registration Number
�
Address Expiration Date
Telephone 5�4;� i
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.152,§=25C(6))
Workers Compensation Insurance affid vit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui ing permit.
Signed Affidavit Attached Yes....... No...... ❑
Home` wne>r"Egemption
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F7 Addition Replacement Windows Alteration(s) E7 Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [0] Other[p]
�1.�WQO
Brief Denription of Proposed \ 0 O
Work: / c \ `
Alteration of existing bedroom Yes V No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.'if New house and or'iddition,to`existing housinq,complete fihe'+following:
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. Masscheck 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,
�, r as Owner of the subject
prop y
I
hereb u orize
to act n behalf, in a afters relative to work authorized by this uilding permit application.\(A'.1�ch A (4 — 15-- d TC
Signature ofVDwher V V Date
I rl� , as Owner/Authorized
Agent hereby declgre 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 =T�
L4— 5 o 6-`-
Signature of wrier/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage M."........
Setbacks Front
Side L. ._, ._ R .._... L:-- - R
Rear
Building Height
Bldg. Square Footage % __... _. _ ... ....,
Open Space Footage __ _ % _.
(Lot area minus bldg&paved
Harkin¢)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book .._...____.__,_.._._�...._ Page__... � and/or Document# _...�___ ..._._._
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued.
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location: __
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northampton Storm Water anNT nagemenf Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
�+ Budding.Department Curb Cut/Dmreway Permit
!- ` 212 Main Street Sewer/Septic
Room 100 WaterlWell"Availability
Northampton, MA 01060 Twa,Sets of Structural Plans'
2 2 yhone'413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Speafy
APPLICAtIOP Tt71C-O�ISTT�UCT,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:
,r� Map Lot Unit
VA �- \�,� Zone' Overlay District
�
Elm St District CB District
SECTION 2-PROPERTY O NERSHIP/AUTHORIZED AGENT
2.1 O e of-Record:
VC� �1kg s
Name(P n) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
2s r�� 3 E ')-i\ S4, QK A 6,'+L-k
Name(Print) Current Mailing Address: �VSS
Signature W Telephone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS -7
Item Estimated Cost(Dollars)to be Official Use Only
completed 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=(1 +2+3+4+5) Check Number
This Section For Official Use.Onl
Date .
Building Permit Number. Issued:
Signature:
npctr Building Commissioer/ Date
BP-2008-0945
WNW
GiS#: . COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0945
Project# JS-2008-001419
Est. Cost: $6865.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq. ft.): 6795.36 Owner: FISHER ADAM E&ELIZABETH R
Zoning:URC Applicant: BOB THIBODO ROOFING & SIDING
AT: 24 VALLEY ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 O
NORTHAMPTONMA01061 ISSUED ON:412812008 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE MAIN 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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 4/28/2008 0:00:00 $25.003149
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo