36-009 (2) 0 t W f p�0
s} 'a Cri s 'of wart 11allyfan
B B l ass achpsctla
m DEPARTMENT OP BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORT COMPENSATION INSURANCE AF MAVIT
N��sc^Jpermi tire)
with a principal place of businesslresidence at:
- re , (phone,'#) ?,741�1717-5;"
(siz�tici[}/sty t.c��p)
do hereby certify under the pains and peaal6es of perjury, Cll?i:
O 1 am an employer providing die following �;or'r er's compensation cove!-age for my
employees worlang on this job:
(Ltsrance Comp') (Policy Number) (Expiration Date) u>
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the followiflg worker's compensation policies:
(Name of Contractor) onsu any Company/Policy Number) (Expiration Date)
(Name of Contrzctor) (n_suranc-- Compa.uyiPolicy Number) (Expiration Dare)
(Name of Contractor) (Insurance Comparry/Pobcy Numbzr) (Expiration Dale)
(Name of Contractor) (Lnsuranc-- Company/Policy Number) (Expiration Date)
(anach additiocal rboct ifnoo=,ry to mchj c infocm=!ioo perYaiaing to a oodrnfl)
e
am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wlrilo homeowocra wbo caxploy persc,=to do t ;rdmanc•.e eoa5mtcdoa'er repair work oa a dwxUing of
not mote th:n throo units is which the bomow,ncr rc3idcs ec oa tho gouodr zppurtcnani tb=w etc oo(gaoa-&y oomidcrcd to be
employers under ibo--kcr`s 0CMpaas4on Act(GL152,ss 1(5)�appti=tioa by a homoow=for a liccasc oc pern may cvidmcc the
legal mama of an employee uodertho Wocicoes compoosation Act
I uodaztand that a copy of altu chremcat may bo foewnrdod to the DoparTu of Iodutsi el Aocidmtl ofSoo tit•Inz-w for thm
coverage vailiestioa and that Gabon to secure cevcrasa under soc4ioa 25A of MoL 152 can teed to th6 impos—of criminal penalties
000sistiag of a-fine brup'to s l,5oo.00—&or imprisoan> of up to ooe year and civil pcvatlics is the form of a Step Wort;Order and a
fine of 5100.00 a:day agpinst me. ,/\\�`'
Signed _d2ly Of ` For dcqut"Cow U-poly
Pcrmit Number
Map4 Lot i!
Signature LiacnscrJPermi
"GT1OI�R.-�'�lil '�#ILi�'F1i�A1'SIi�YICES.
u.1 Licensed Construction Su er " Not Applicable ❑
Name of License Holder
License Number
Addre Expiration Date
i Telephone
-- r
.. 3�1 -2111-10 w. Not Applicable ❑
Company Name Registration Number
Address
Expiration Date
Telephone ��
E-CT.IQN";1f? .1 ORKERS' CIs,�MPENSAT101N INSURANCE A FIDAYI7'(M.G L.,c.152, §2500))
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.
fined Affidavit Attached Yes....... ❑ No...... ❑
;Fs.
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
CTIQN 5 QESCRIP'TtON OF PROP IEIE 1iV f~tl check atf.appl carCile):
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other [ ]/
Brief Description of Proposed Work:
- 7 9�
Alteration of existing bedroom Yes No Adding ne edroom Yes No r1a
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑• Sheet❑
ffift
s3?
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?
.. 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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, r/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 un ains and penalties of perjury.
O E- -
Print Na 9
.'e
Signature ol@111111111111WAgent
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:
veit bf�Northampton
lding Department
21� Main Street
Room 100
Northampton, MA 01062
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S. IbN:I:-SITS INFQRM"AT101�1:
1.1 Property Address: $ ',
u � r a8
M ,�' S4 7i ` i
-S'ECT1 12- PROPERI Y t Wl l R "HIR�AUTHQ.-I ED,A ENT
2.1 Owner of Record- 1 /
Name 99(Pri t) Current Mailing Address:
Telephone
Signature
2.2 Authorized A �?
Name(Prin Current Mailing Address:
Signature < Telepl�o e
SECTION 3 ESTIMATED CdNSTRUCTION CONS
Item Estimated Cost(Dollars)to bea�O—Q Official Use Only
com feted by ermit applicant l�
1. Building (a) Building Permit Oe
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 Section For Official Use Only
Buildirig Permit Number: Date Issued;
Signatr��e:
Date
Huildirtg.Cornm ssEArler/Inspect r afi Builrlings'
46 FOREST GLEN DR BP-2001-0338
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-009 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Catego1y:roofin BUILDING PERMIT
Permit# BP-2001-0338
Project# JS-2001-0551
Est.Cost: $4765.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 15 8 1 2.28 Owner: QUINN SARAH
Zoning_URA Applicant: Robert Thibodo
AT. 46 FOREST GLEN DR
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON.9/28/00 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & SHINGLE MAIN ROOF
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 9/28/00 0:00:00 7396 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo