35-202 (3) C Q(tU�11P�0
� � e
e Git� >af Yart11alrlptnn
a
� • �asaacfltsartla
m DEPARTMENT OF BUIL)r NG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE A YITDA.VIT
(licen_seclpermittee}
with a principal place of business/residence at:
( ty/stalr/ap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am as employer providing the MoNving workers compensation coverage for my
employees working on this job:
(nsi=oe Company) (Policy Number) (Expiration Date)
a sole prop riet , gal contracto meowner (circle one) and have hired
the contractors listed bel e e following workers compensation policies:
(Name of Contractor) ce Co fPoticy Number) (� lion Date)
(Name of Contractor) Jinsurance Company/Policy Number) 4xpird6on Date)
L✓ 6e037/oZ4Io2LOA
(Name of Contractor) (Insurance Compaay/Pohcy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(attach additioail sheet ifncr=z to include infr tioo pextaiuing to aII o�rncton}
( ) I am a sole proprietor and have no one working for Inc.
( ) X am a home owner performing all the work myself.
NOT$:plcaaa be await that whilo homcotitvm who employ pczou to d,m,iatc=• c corr%trvdioa or repair work on a dwelling of
not moee than throo unit+in tvEch the hombowncr raids cc oa the goun6 appurtenant thado ate oot CCacrally oomidcrcd to be
cmploytr3 under the worker's 0=rpcatjca Act(GL152-"1(5))�appL caEon by a homoowncr for a license cc Permit may-idcryoe tho
legal status of an employer under the Workoes C.ompomation AcL
1 understand thst a copy of this critemeat may be fawnrded to tho Departx�of Iodauhial Accidcn&Oflioo of In�for the
covaxge vailEcdioa and that failure to sewn cowmgo under sxtion 25A of MGL 152 can lad to tha imposition of merit Pc-WIts
0o of a fine of up to 53,500.00 andloe imprison of up to one year and avt7 p=d ies in the Cam of a Stop W Otk Order and a
fins
a(5100.00 a day against Ew-
a
Foe use Only
Permit Number
Map# Lot#
yy'y, of i 'lice e
IF-.
SECTIQN 8 GONS7RUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
R Ill r . e"M n n ra t f�. Not Applicable El
Company Name Re istrati n >umber
Address Exp: ati(A Date
Telephon %2/
SECTIQN 10 WORK, .ERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.,
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 t ilding permit.
Signed Affidavit Attached Yes....... No...... ❑
Q. { , 0,M W
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`ttiat 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 persons)
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
SECTION 5= DESCRIPT10N'OF PROPOSED WORK(check all-applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ [Roofing iler
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a.JU New lid"use" anf`d or.yad°diti,riAp dxi stink-fiousin , completeaiie:foliowln :
a. Use of building : One Family !l _ 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?
In. 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:CONTRACT0 APPLIES FOR BUILDING PERMIT
4�;,01-1
as Owner of the subject property
hereby authorize ! ,1i to act on
my behalf, in all matt s relati e to work au t orized by this building per/nit applicatio .
Signat e of Owner Date
I Y" �,, ,�. � J j ,L , as Owner/Authorized Agent
hereby declare that the statements and information on the for going application are true and accurate, to the best of my
knowledge and belief.
Signed undpar the pa' and penal#ies of perjury.
Print N me
Date
Signature of Q er Agent
• w
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&L.ocation
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
i
IF-YES, describe size, type and location:
City of Northampton 5 0
Building Department
212 Main Street Se erne" f
Room 100 a erJ
Northampton, MA 01060 T Sets a >
phone 413-587-1240 Fax 413-587-1272 Plo
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office;
1.1 Property Address: �
0�- 13,ur,/- J //I
T Z, Map Lot llriit
Zone Overlay District
Elm St.District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner.-of Record:
Name(Print) Curre t Mailing Addr ss:
Js'
—
_ Telephone
Sig ' ure
2.2 Authorized t:
C
Na „e(Print) Current Mailing Address: _Or
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. Elecirical (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 Section For Official Use Only
Building;Permit Number: - Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date.
BP-2003-0502
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Perrnit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0502
Project# JS-2003.0829
Est. Cost: $4860.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PHILIP BEAULIEU HOME IMPROVEMENT 020529
Lot Size(sq. ft.): 48787.20 Owner: HAGUE GERALD C&SUSAN C
Zoning: SR Applicant: PHILIP BEAULIEU HOME IMPROVEMENT
AT. 1292 BURTS PIT RD
Applicant Address: Phone: Insurance:
217 Grattan St (413) 592-1498 Workers
Compensation
CHICOPEEMA01020 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:STRI P ROOF OFF HOUSE & GARAGE, ICE &
WATER BARRIER, REROOF 30 YR
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 11/14/02 0:00:00 7619 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo