35-107 (2) F `E Git�) of 'Nortilailiptoll �—
�Znsinrhnsrite' —
u o DEPARTMENT OP DU(LDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01000
WORICI R`S CO)IMENSATTO INSURANCE All �1V1T
1 CC71S:X'J pCT'tIl l t 1CC)
\vlth a principal place of businesshcsidence I�
f-
(stlreUcitytstatc'inp)
do hereby certify, under the 4-ns and penalties of perjury, ?hal
( ) 1 2-m an employer providing the following worker's comnensv:jon coverIge ;or my
eluplovccs wor-�Qng oil iiiis job
(LnsIu-.--0C:2 Corr,:y) (Pahc;Nu--ab--r) -_- (� ;pir Cior, Daic)
I aIn a sole proonetor general contractor or homeowner (circle one) and have hired
the contractors lister below vyLo h2ve the following worker's co oe ion policies:
R"groc of con -: Iczo-) O(1R![3lll;; Colnoan}l1'cuc, ?�'um'cc;) ('L'?:Jlii?liQi? l�3lC)"
(Name of Contractor) --- - (trill--Doc Comoa-uviPol v Numbs) (-ExpLFZuon Date)
(Name of Conn-aclo;) (Laufanc^_ Compaoy/Poucy Numb,-s) (E�pimbon Date)
(Nzmc of Contractor) RnSluan� Coma: y1Pohcy Numbs) (L=xpuauon Daic)
(nnach c'�ct itncccv to irx?ucf,infocmi.ioo f—r iaing to.11 ooa-r-r_o.�)
an a sole propnetor and have no one wor}dng for me
( ) I am a home owner perforr=. () all the work myself.
NOTE:plcx be eauc tiu kf 1c boa cn x""to cmplay p, r53 r, cc�^c� G rrpau.a6 on r d,,t^.g of
not cmKC b n two Luyj in wt,":b the lwtnooav r rr.ido or oa the Vouncii rppvrtcn>r1 tbcti 2 aoc C�nv a-cr:d--Cd to R
rmploycs un c Lbc _tim iW(GL152-"1(5)) application try.bomco-na far c brx=o<perma n-:y cvrdcatt trc
Icgil r nic of nn cx;Iloyer uodcr d--Wor4o(a Corapow lion A-r_
I uz4crgwd that a copy of tbit 4itcmcn3 m..y bo fl—Hied w tbo Dcpertmccst of tnd.ss'aid Amdcutf Moa of b— for d-
oova-L, vrr6cmiioo mrO t}u f-ilrnc to cocwc`covcrnsc under soc:6oa 25 A of MGL 152 cw lmd to the L-9>01 ca of C iminA pCas1 ics
ooan.is of a f1Dc of up In S 1 500.0o.rid/«jnapri30Q32>CZd orup to ooc year tod a%il peashia to LSc form of.Stop Work Order nod.
fim a(S 100.00.dy tpinn mc_
For ---
dW'm l u.c only ------------
�' Pcrmtt Numbcr
; _ Lot
Si .tun of Liens cr i crmiucr
f
SECTIONa CRIPTIOt�033PROPOSED WORK(ch`eck#a311 apalicable)
a:
n
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description'6f Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑_ Sheet❑
sa 1`f New douse and or addition fo ezistihiT uM C Oft 01&1 e ttie"following:
a. Use of building : One Family_o� 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
OWNERS AGEN7.OR CONTRACTORAPP.LIES, FOR-BUILDING.PERMIT
,
G 4 t 6 Vs k as Owner of the subject properi
hereby authorize _O � i— Ifn,L' b U CLO S C! h to act
my behalf, in all matters relative to work authorized by this building permit application.
Sig4atofow ner Date °U
H as�►ar/Authorized Agent
hereby eclare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the d penalties of
Print Name
LSignature of r/Agent D
SECTION 8-CONSTRUCTtON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �/' 7` �� CS
License Number
Addr Expiration Datir
r_r �v
Signat re Telephone
' Not Applicable��. ,� � pp 'cable ❑
Company Name ,� � _,..�✓/� _/ � n� � j�°� Registration Number
Allrlloe /S W,
Address �77 Expiration Date
elephon
1
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§95C(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 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
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
Thr$S p be comp
1.1 Property Address: x r
/0
Map 7 y s Una r
` Ga d� Q/lJ�vo� L +e A, ti yrlt r ; ✓ X �� '.
St.dl Qf�st4
., ,.�, ri
,z -
SECTION 2- PROPERTY'OWN ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
9
Name(Print) Current Mailing Address: z1
Telephone
Signature
2.2 Authorized
C/1
Nam {int) Current ling Add .' '717 L//y�7�`
Signatu Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS v
Jf"r°
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building r (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check Number
This Sec#ion<For Official U$s 'Qnl
Building Permit Number: date Issued;
Signature:
Building Commissioner/inspector of Buildings Date!,
woo
BP-2002-0022
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0022
Project# JS-2002-0027
Est.Cost: $4385.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(ss .ft.): 901 6.92 Owner: SLABINSKI RICHARD P&JOAN B
Zoning: SR Applicant: Robert Thibodo
AT. 86 DREWSEN DR
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON:7191010:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE 2 LAYERS, VENT & REROOF
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 7/9/010:00:00 7682 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo