29-017 ` 4�ttA1'lPJO
Bzo laf 'Nart 11allip toll
8 e �azsxrhnartta'
t
m DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
(licenseeJpermittec)
with a p cipal place of businesslresidence at:
(phone#) a/ ` 7
(stre city/stafe/np) v
do hereby certify, under the pains and penalties of pequly, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(las urance 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/PoGcy Number) (Expiration Date)
(Name of Contractor) (Insurance Compairy/Poficy Number) (Expiration Date)
(Name of Contractor) insurance Compaay/Policy Number) (Expiration Daze)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addWoml sleet ifneoe ss xy to inctude information pertaining to all oo txn m)
(,Pf-�am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that v?aUo homcowo=who employ perz to&=&kdcaanc,,co¢stnldron ar repair work on a dwelling of .
not more than three units m which the homoowncr rmdcs or oa the grounds apputtcnant tharto arc not gcocraly coc sidacd to be
employes undo the worker's s4oa Act(GL152,ss t(5)),nppUcition b w y a homco =for a Beene or pctmit may evidence the
]tgal ctanrs of an omployer under the Woriccla Compensation Ate-
I understand that a copy of this aatcmcat may bo forwart6d to tho Dcpo't of Indr>s4ial Accadn&Offi—of lass"`°°°for tho
coverage verification and that failure to accrue covcmgo unckr scetioa 25A of MGL 152 can kid to tha imposition of criminal penalties
ooasist of a fine of up to S1,500.00 and/or imprisonnxat of tip to ooe year and civil penalties in the form of a Stop Work Ord--and a
faro o(3100.00*,day ag&iwt mo.
For dcpar'off 7 only
Permit Number
Ivfag Lot#
si of LicensedPermittee e :
a . 2
SECTION 8!-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number _
Ad re Expiration Date
3
S' nature Telephone
9Refri� etetl H2irne-lmprovement�Contractor.,` „ wt Not Applicable ❑
RAC,
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'.COMPENSATION INSURANCEAFFIDAVIT;(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...... ❑
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 fob 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 ofMassachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION"OF,PROP4SEb"WORK"(check all"applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Atd
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Adding ne bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a" tf:New h"ouse"arid,or.addition'to:_ezisting".lion ingr completeahe"f611oWJng:
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 0WNEF5'UTHrORUATION TO I3E COMPLETED WHEN
t7WNERS AGENT'ORGON`�RACTOR APpLIE,S FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize C ,1 �i� � to act on
my behalf, in all matters relative to work aut orized by this building permit application.
Signature of Owner V Date
c
as Owner/Authorized Agent
hereby decl e that the st tements 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
Sig ure of Owner/Agent Date
w f'
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:
R �
�r;sci"ty of Northampton Sfatu Hof Pei
gilding Department
Z12 Main Street Sewer/S ptr a
Room 10D Wa eI�We va t �� �
tpne Nort mpton, MA 01060 Two Sets o S r a
3-5 7-1240 Fa x 413 587 1272 Plot/Site P a Ys �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sectionto be�completedby office
Map Lot It
F'
� ,Zone ,� �OVerla Distr ct� X11
ZZ R"',
b b T 3% jps 3
Elm St strict, 41, -^�01 1 tri t
SECTION 2- PROPERTY OWNERSHIP/AUTHO.RIZEiD AGENT
2.1 Owner of Record: \
Name, rint) — Current Mailing Address:
Telephone
Sign ure
2.2 Authorized Agent:
y e--M/--S .& �=/C —5,
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - EST PMATfD CONSTRUCTIOMC;TS i
Item Estimated Cost(Dollars)to be Official Use 0lly
complete b y permit applicant
1. Building (a)'Building PerrnitFee
2. Electrical (b) Estimated Total Cost of
Construction from 6'
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
ignatu,rQ _
Building„Commissonerlinspector:of g�aildcngs jr t
BP-2002-0915
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-0915
Project# JS-2002-1490
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Sizssa.ft.): 18382.32 Owner: LIEBL STACIA E
Zoning:URA Applicant: James Roberts
AT. 36 HICKORY DR
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:4123102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/23/02 0:00:00 1873 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo