36-013 4-Ct1AMPT0
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DEPARTMENT OF I UILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
LX
(Iicensee/permittee)
with a principal place of business/residence at:
(phone#)
(strccucity/staw2ip)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance 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/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sbeet ifnecc to include information pertaining to all 000tractors)
O I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please lx aware that whilc homcovjo=who employ pazom so on or repair work on a dvlcl n of
not mono than throo units in winch the hon=vw nicks cc oa the grounds appurtenant thereto arc not generally ooa ndcmd to be
caVloycrs under the woricu's,ration Act(GL152,ss 1(5)�application by a homeowner for a be==or permit may cvidcaoo the
k821 0-t- of an employer under the Workoet Gompomation Ad
I undauaad data copy of this cu temmt may bo forwa,%W to the Departaxrd of Inrhutrial Aocidmt&Offioo of Insur*nco for tho
oovcr g vcnfiatiioa and that failure to s==coverago under souion 25A of MGL 152 an icad to tbo i on of aiminsl penalties
coasisting of a fine of up to S1,500.00 and/or kTrisotra3ent of tip to one year and civr7 pcs&Wc3 is the form of a Stop Work order and a
firm of x 100.00 a day against tnc_
Foe depart u10 O°ly
/2gSj p# Number
Lot#
Signahtre of Liceaseelpemiitfee 1
v
a
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECx14N�01NOR ERS COMPENSATIONINSURANGE AFFIDAVIT(M G
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
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)familie,
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.
,_,,XHomeowner Signature
IF
ye
I
a
WHOM
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
=Brief Description of TPoposed Work: rc-p 6l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0. Sheet 0
Jill I '. :et J- i
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 J
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
Q� a, CX 'IOECO PE�T� 'WREN
as Owner of the subject proper-
hereby authorize to act
my behalf, in all matters relative to work authorized by this building permit application.
"Signature ner Date
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 penalties of perjury.
't) J ,,A GS
Print Name
G
Signature of Owner/Agent Date
tt
w�n
1.
ro+
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
x 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:
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
STON1 SITE INFORMA10[ ',
1.1 Property Address: �
u
SECTION;2- PROPERTY OWN ERSHIP/AUTHORIZED kGENT
z.,
24 Owner of Record:
Name(Print) Current Mailing Address:
O" Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- 1=S7°fMATFb°0� 154 RIGT#ONC�b`STSr
Estimated Cost Dollars to be Off[ciai U �C
Item (Dollars)
completed by ermit applicant
1. Building X100 a) Building PermltFee`
��
2. Electrical (b) Estimated Total Cost of
Construction,from 6
3. Plumbing Building Permit Fee'
4. Mechanical (HVAC)
5. Fire Protection 'r`
6. Total =G + 2 + 3 + 4 + 5) Check Number „
Thi"s Section For Official.Use;Onl
�
i ullding(('e? n t�lumber -Date l'ssued:
-
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BP-2002-0208
G1S#: COMMONWEALTH OF MASSACHUSETTS
g13 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0208
Project# JS-2002-0327
Est.Cost: $1728.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sg.ft.): 13982.76 Owner: COSTELLO DEBORAH&EDWARD
Zoning.URA Applicant: COSTELLO DEBORAH & EDWARD
AT. 53 FOREST GLEN DR
Applicant Address: Phone: Insurance:
53 FOREST GLEN RD (413) 585-1568 ()
FLORENCEMA01062 ISSUED ON.81231010:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SH I I N G LE 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 8/23/010:00:00 3142 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo