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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOMI�--E'R'S CONDENSATION INSURA-NCE A F A.VIT
I�A
(licenscrJperulittee)
with a principal place of business/residence at:
�� vtit t�l o� (phone#)
(streeUci ty/stalrhl p)
do hereby certify, under the pains and penalties of perjury, that
O I am an employer providing the following workers compensation coverage for my
employees working on this job.
(Insurance Company) (Polio Number) (Expiration Dale)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workeCs compensation policies:
(Name of Contractor) (Insurance Company(Poky Number) (Expiration Date)
(Name of Contractor) (Insurancc Companv/Pohcy Number) (Expiration Date)
(Name of Contractor) (lnsuranc�t Company/Poticy Nuirllrs) (Expiration Date)
(Name of Contractor) (Insurance, Comp=y/Policy Number) (Expiration Date)
(attach additional Lfnocezury to include infocT ioa pertaining to n11 ooctrndnrs)
I am a sole proprietor and have no one woi-Eng for me.
( ) I am a home owner performing all the work myself.
NOTE:plcaac be amts that whito haricowncn wbo cmplay pcTons to mat„+�co rs C on cr repair work on a d«ctling of
not more than thmo units in which the honioouvcr resides or oa the grounds zpp utcnani lhcdn ere not gc�y oomidacd to be
cmploYcs uadcr the workk s compcaaticn Act(GI152-m 1(5)�appticat;on by a homcowacr far a U—sc cc permit may cvidcaoc the
legzl statics of an omployec under tho Worko1s Compemafion &.d-
I understand thai a copy of this rtatcc m may bo forwnrded to tho 1}cpnrt or of Indzutrial Ao6d,A'OfFoa of Inairs000 for the
covcrago vaificatioa and that failure to:,:�cztn cove a under scuioa 25A of MGL 152 can lend to tha impoviioa of crimintl peuakies
ooasisting of n fine of up to S1,300.00 and/or im{uisonmeat of up to one year and civil pcadtia in the form of a Stop Work ordc and a
fim 0(s I OO.W i day against mc-
For dcpuuirs�'1 a'0 oaly
Ma ,l Lot 4
P' _-----
SiPa of Lic=scc1Permittcc e
SECTION 8=:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : G+t y+�C S �. �d SS 67 4-I a_
License Number
Address Expiration b�te-
Signature Telephone
fF� rY a k Not Applicable ❑
9:Reg��tered,Nb""m 1mprQvement Contractor .4, �-� ��� ,, � w= a pp
90) ) 307,) "7
Company Name (/ Registration Number Address Expiration Date
�7
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...... ❑
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
Sf Ti 5 DESCRIPTIONOF PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Windows' Alteration(s) ❑ Roofing (
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] + Decks [ ] r iSiding[ f] Other [ ]
Brief Description of Proposed Work: S 1 Z l���l'f_ �DIh n�d� fecu� �d CSSOI�a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
�►. If�New�house andor��`addition`fo exi`s#Ing-tiousin�,�.complete�the`�followin"�:
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! OWNERvAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS'.AGENT OR'CONTRACTOR APPLIES FOR BUILDING PERMIT
C ` ` 5G�' "` ` as Owner of the subject property
rereby authorize Mk ��`» - �Q I LIX ' S to act on
my behalf, in all matters relative to work authorized by this building permit application.
g er Date
n,\e � /V � h 2 )i R S , 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 penalti s of perjury.
r--
Print Name
-- l 6 7 (1063-7
Signature of Owner/A94 t 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 N 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 S atus�gf P r .
Building Department C urbCutl; v
212 Main Street Se erl, ep��
Room 100 Waal�er/We a .
Northampton, MA 01060 Tw�Setso r a, �
phone 413-587-1240 Fax 413-587-1272 Pio t%SIIt: Pala
Other Spec
. a
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
f I Jcew.a�^^ L) Map Lot Unit
L)f,r 1110-FM le b"I i 1100 .
Zone 00r1ay.District'
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone ii - ---- —`-
�g a
2.2 Authorized Agent:
_ — ass Ic Ac (� C�a� e��.,� wa-- 6)e` —
Name(Rant) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b permit applicant
1. Building 2 (a) Building Permit Fee
2. Elecirical (b) Estimated Total Cost of
Construction from 6
:S. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
a
BP-2003-0371
GIS#: COMMONWEALTH OF MASSACHUSETTS
ltt :910 ck:35 123 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0371
Project# JS-2003-0616
Est. Cost: $6200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: JDR BUILDERS 074104
Lot Size(sq. ft.): 8015.04 Owner: CIASCHINI MILDRED E&GARY F&
Zoning: SR Applicant: JDR BUILDERS
AT. 19 DREWSEN DR
Applicant Address: Phone: Insurance:
P O BOX 66 (413) 665-7587
WHATELYMA01093.0066 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-STRIP 2 LAYERS, PLYWOOD, REROOF
W/ASPHALT SHINGLES
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 10/8/02 0:00:00 1259 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo