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DEPARTMEITF OF BUILDRvIG INSPECTIONS ==
212 Alain Street ' Municipal Building
Northampton, Afass. 01060
WORKER'S COMPENSATION INSURANCE AFMAN I-I'
ith a prmi ci�p�a_ll place of businesslresidence at
(stmt/city/stalLhz p)
do hereby certify, under the pains and penalties of penury, th t
( ) I am an employer providing the following -cr's colnpcnsation coverage for lny
earplovees worming on tills job.
(In_U=c;c Compam) (Pclic.,NLLmtrr) (E pinion Dale)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors hsted below who have the folloWm' 2, worker's compensation pohcics:
(Name of Contractor) (InRlrancc Company cue; N=bcr) Date)
(Name of Contractor) (Inssrancc CompanyiPolicv Numcrr) (F_aplraoon Date)
(Naive of Contractor) (Insurance Company/Policy NiLmbzr) (Bpiratio❑ Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additioml sheer if noocn ry to iodide rnfQr o.% o;,art m c w nil ooasnc o s)
(L)4 am a sole proprietor and have no one working for me.
( ) I am a home owner perforTning all the work myself.
NOTE:pl=sc lx aware[1ta1 wlnlo homoowncrs who craploy pc tom to d>m n ConSruction or repair work oo a d. Ahng of
ant moeo than them units is which the bomoowncr resides or oa the groins appurtenant tb_— t arc no(gmcrally 000sid«cd to be
employers under tho worica'z eccapcns-aurn Act(GL152-=l(5)�apptirsbon by a homeowner for a(cans a pc;r i may cvrdraoe the
legal 0-xnLLa of an omployer under rho Workm'&Cocvoosation Ac_
1 undcrsand dDd a copy of laij r cmcm may be foawaided to tbo Dcpeonr d of lMxri!I ej Acadccl 0f5oe of Isrurinoe for tho
covcntgc vrri cstioc wad that L•ilurc to acatrc coven tmdcr suction 25A of 1.tOL 152 can lead to tba imposition of crimmsi pcnallin
ooaauti of a fine of up to S1,500.00 andor of up to one year and civil peoattics rn the form of a Stop Wori;Order and a
fim o(:S 100.00 a day against me--
For dcppatm�rlil uac only
Pcz-mit NtimUcr
Map;,' L
ot rt
Signature of Liccnscc/Pctmiucee
r.0 , Ao
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder -
License Number
Address Expiration Date
Signature Telephone
9 Registered Home lmprovement'Conteactor: Not Applicable ❑
N -Name' a _ /16069
Company� Registration Number
Address / ,I Expiration Date
/..9 Telephone
SECTION 10-WORKERS' 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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
Home iywn&r,.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
V . .,
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 5'TPIP 406Y 'Ai•N'y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll G- Sheet I=
6a. If New house and.or addition'-to existiniz housing, complete the 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. 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
, 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
I Z cam" 4,66e-,J-)- , 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
igna ure o caner/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:
\�(7 l C �.,,+ ��*5' �� �„�` #��i.,-. e �1�7 n-•.I '� §
i y of Northampton
r � 4 errs
2� 'Iding Department C � e �
,UN ` 12 Main Street erpt ova akltYe '
Room 100
; a rlGe If 111
„ y ��'� rthampton, MA 01062 wotscs oral Plans � � '
_.-
OE � 4f3.587-1240 Fax 413-587.1272 � I�lte lrart� I
i
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section-to be completed by office
Ma Lot" I nil
wet-
�1 / Iyo�c p = �
' Zone Overlay District
Elm St.District CB District
SECTION 2 - PRO'PERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
b Ac-0(tc:q
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Adjdrress:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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) 3/tJo Check Number APE
This Section For Official Use Only
Building Permit Number: jDatelssued:
Signature:
Building Commissioner/inspector of Buildings, Date
�i
Alp
' s,
1010A&RL00K DR BR-2000-1135
GIs#: COMMONWEALTH OF MAS .CHUSET"IS
Ma :Bl ck:29-256 CITY OF NORTHAMPTON
Lot,-001 ,
Permit: Building
G PEMT
Cate¢ozv:r�fins IEu N
Permit# BP-2Q00-1 135
`Przjt JS
-2014
Ik $3100.00
Fee:$2A.00, PER ISS"I ONIS.'Ut kBY GRANTED TO
C-04 Class: Coittructor: License:
use Grave: Ed Corbett Jr, 11'fiQ6,9
Lo Nzedsa.ft.): 15202.4$ Owner: ALDRICH DALE
Zonins TItA 1 IGiltt E t)ft r -,
L.- 101 OVERL�CIK.DR
sP.lgntk
:' - t�urur .
# eeci S A 1
, 6-
It3RTHAMPTCt1M #'!t6(? I :00
TO' ' F'OR`1!IT1 'IILOG 'l►R . v
T C IE E om T
I'll'' or of Plumt►ii Ios ctor of Wiring D.P.W. Inspector of Buildings
IUndei oyno: Service: A�eter:
Footings.
Rough: Ro : House# Foundation:
Final; Final:
Rough Frame:
Gas De Fireplace/Chimney:
Rough: C3il' Insulation:
Final: Smoke: Final:OA 7-G
THIS PERMF MAY BE REVOKED BY THE CITY OF NO OF
ANY OF ITS RULES AND REGULATIONS,
n e.
Fee No D aid: Check INC AMOUnt:
Building
6/15/000:00. . 3560 $25.00
r
,
212 Main Stt*et Phone(413)587-1240,Far:(413)587-1272
Building Commissioner- "Pala