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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOMI�T,R'S COMPENSATION INSURANCE A-FMAVIT
(licenserJpermittee} ----- -
with a principal place of business/residence at:
_ (phonet#)
(street city/stair/a p)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurancc Company) (Policy Number) --- (Expiration Date)
I am mole proprietor general contractor or homeowner (circle one) and have hired
the contractor�lsste'rt-te'o`v who have the following workers compensation policies:
(Name of Contactor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Coutr ctor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (InSuranc-- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additkKIMI sfxct if neocav fv to inc�inform on pertaining to all oDatradors)
(�) I am :a sole propnetor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plc-ac be aware that wfrilc homco".o.=who crnploy pazo¢s to do mamtC Rn con:st i oa or repair work on n dwelling of
not UK—than throe units in Which the bousoowacr r=dca or oa the grounds appurtenant thereto arc oo(gc al y cc-mid«cd to be
employers und ct the worker's compensation Act(GL152,s3 i(5)�application by n homeowner for a Lccax a permd may cvidcaoc the
legit etatur Of an employor under the Worlcoes Compmsalion Art.
I understand tbvt x copy of this rXatcmmi may bo forwwdrod to tho Dcpnrt nc of 1.&1$iCl A,:zdcn&OfSoo of Inxu.noo for the
covmtgc va'ification and that failure to acc=oovt r. under section 25A of MOL 152 can Icad to the imposition of criminal (
pe AW s
ooaaisting of a fmc of up to S 1,500.00 andlor imprison of tip to cm y=and civil pcaaYtia in the form of a stop Work Ordcr acid a
firm of 5100.00 a day ag¢iast M--
For dcpsrhn—W uao only
l ? Permit Number
Lot
# —
r Slgaa of Licensee crmittce e
SECTION 8—CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder :--c c3 VUL h �� /V/o(`- _
License Number
Address Expiration Date
;fr 6l-
6ignature Telephone
Not Applicable ❑
�Fte is �retl }come fm'rouemer t Con#ractq ff. US ��.:�� -
Company Name Registration Number
Address Expiration Date
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...... ❑
11: -: HomeOa nexn�pa►°n
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
SECTIONS= DESCRIPTION�(OF PROPOSED''WORK(check all applicable)
"..gyp.n.0 a ,»a>a �.L. +e, d..s:IX. .•F.M„..f i[ +�- .ig, 3 >.?-.
•m
New House ❑ Addition ❑ Replacement 1lYindows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding VIT/ Other [ ]
Brief Description of Proposed Work:fZCPIA,-E' U,151 IM' 1sila'J���
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
ha if Nevii house°a itl o Nit>lo plete the fol'lowin�:
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
eR OWNERS AGENT.611:CONTRACTOR-APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby au horize to act on
my behynl,, in all matters relative to work authorized by this building permit application.
Si nature of Owner Date
as 9wner/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.
('(I /� ?
Print Name
signatu e 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:
City of Northampton
Building Department
AWinStreet
100
R; �� f<tt�rt aTi�r {fit :r�i MA 01060
phone 413587-;.;2 Fax 413.587.1272
�]❑❑ yF
A PLICATION TO_CONSTRUCT', ALT R, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
M
SECTION 1 -SITE INFORMATION
This section to be compFeted by office
1.1 Property Address: ,
/l 73 Pc atrj rn1 � 'C� Jam' Map Lot Unfit
F� ^ Z06,6 Overlay Distriict
Elm St."District CB District
SECTION'°2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
' � Telephone
Si ature
2.2 Authorized Agent:
Name(Pr nt) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Bu:;.ding lc'f 'L4(G r,/A/P`'`" (a) Building Permit Fee)17 upol'K
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) '' c� (i Check Number
This Section For Official Use Only
Building Permit Number:_ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1173 BURTS PIT RD BP-2002-0852
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-092 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2002-0852
Project# JS-2002-1414
Est. Cost: $8345.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sg.ft.): 8668.44 Owner: FENNESSEY KAREN L
Zoning: SR Applicant: FENNESSEY KAREN L
AT. 1173 BURTS PIT RD
Applicant Address: Phone: Insurance:
1173 BURTS PIT RIB (413) 586-2891 ()
FLORENCEMA01062 ISSUED ON:419102 0:00:00
TOPERFORMTHEFOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/9/02 0:00:00 134 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo