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36-051 r r o (� &t 3 Jf PortIjulliptoll 9 E jQIx3sactlncc(Ia o DEPARTMENT OP BUILDFNG INSPECTIONS 212 Main Strect ' Municipal Building Nor(hampton, Mass. 01060 «'O R1CC R'S CO)IT EN S A`z'IO N INS URA-N CE A FIR A VIT i ccvsccllxnni ttc�) %with a principal place of business/residence at! (phone:')-L r� (sQ�,VyM ty/scal7,2 i p) do hereby cerdi ;, under tlic Pan' s and penalties of perjury, :hat ( ) I am an employer providing the following worker's cotnocns-�:ion cove 2ge for Illy eluptovecs worUng on tills job: (Innis---Oc-- Comrazy) (Pclic; ?�umtrr) --- (r ;pir tion Datc) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the cootractors lasted below who h2ve the '10HO vtug workers wm;)tns-P-non po!icies: (Name of Co !rae-Lo-) (Ins nnc Company/POUC; NumL-:-) >trat:or. Date) ,� (Name of Contractor) (Insurance; Comaaa.•iPo!ic,, Numc-�F)- (-Expit Lion Date) (Name of Conrracio;) QIlSWa-nCa Com>tan)•/POI cy Numbzf) (Expir000 Datc) (Name of Contractor) (Insurance ComGauy/Pohcy Numbs) (ExPiratioo Date). (anad�ad�':iocai r'_uc:if ncxis:� to mcu�info�,_ioo pcsv:inins to nll ocu7-_r_o:�) ><I am a sole proprietor and have no one worLng for me. ( ) I am,a home owner performing all the work myself. NOTE-.plc- :be&wise tt .W, c be -xorn r�uoo crnplcf pc's to do c-xxci.-,.,,.Y rc uu Fors:on a d—W-oE of on(mom than U--r=L-ari to wtnctithe bomoowan rrydo oc co the Vcyj r zppurtcn.r.+.tbc_o LT we Sexrally oeesd.-- : cd to be catplcy—unGc the--kc'=o slim Act(G L152,-rs 1(5)�rpptici600 by a bomno-=fm c tics__oc pc7mrt rn-y`i,& o LM lcp.i O-fiu or ea-=p loyoc twda dw W or'c ,Coompom.iioa Aa- I undo%% nd df d a oopy of this eru--i o y 1�for'. xiod to tbo Dooe i—.a of 1nduT.rie1 Aendeuw OfLoo of 4ac+r.000 for tho covcvxgt vcriGctioo and th_t L.A6m w cccurc covcmgb ur dcr suction 25 A of MOL 152 an Ia.d to the i •'tioa of o'n'us'pcw'Wi oomutiug of■floc GNP to S t 500.00 arWO,-imrq� of up to as yr,tod a vi)pmahia;n dx form of a Stop Work order and a fim of S 100.00 l d-,y c&ziast me F71,n==�1 use only umbcr I of turn.of Liomscc 3cnruttc- —�� ,rR SEC7lDN$-C�1N�TRtiCTI©N Sl"RY,C��;, .1 Licensed Construction S ervisor: Not Applicable ❑ Name of License Holder Licener Address Expiration Date gnature Telep one Not Applicable ❑ Company Natbe Registration Number Address Expiration Date Telephone SE0T1dN 10.1,CYRKERS CQI IPENSATION:INSL#12ANCE A&IDAVIT(M.G.L.;. 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 w PfM!'MN,OE PRO O O K che' 4t is ble New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] rief Description of posed Work: Alteration of existing bedroom Yes Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 S�C7' OWNEft AUTHt1RlXA71QN;-TO �LgTE D WH9N QW � NT34R;��3N'�RAGT+�R bP1�L15.�'OR'BUILDING P��iMlT - as Owner of the subject property he by authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner 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. Print Name r Signature of Owner/Agent Date i Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE °w NIED 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 a er 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 Commi ion? Needs to be obtained Obtained Date Issued: i 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 6 2Q00 Building Department 212 Main Street v� Room 100 {� +PjC !"c701c .n"' 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 SIT NF INF. RI1lIATION �`Thrs y' tia�ta}fa e camplete�d 1.1 Pro ert dress: y ld w* `' c #�aistrlct' n C�C3trict SECTION 2:- PROPERTY OWN ERSHIPIAUTHORIZED AGENT .1 Owner f Record: / Z�2 i1 Name(Print) Current Mailing Address: c ll�l , Telephone - signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CON5TRUCTION COSTS', Item Estimated Cost(Dollars)to be Official Use Only c m feted by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b)_Estarna#ed Total Cost,of Conitructio6tf M 3. Plumbing Building Permit Fee 4. echanical(HVAC) ire Protection 6 Total =(i + 2 + 3 +4+ 5) Check Number TIJN Section For Official Use Onl Building Permit Number. [date Issued. .signature: wilding Cornmissignerlinspector of Buildings Date i 12 WHITE PINE DR BP-2001-0008 GIs#: COMMONWEALTH OF MASSACHUSETTS r*AIM*Block: 36-051 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2001-0008 Project# JS-2001-0024 Est.Cost: $3800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: James Roberts 117154 Lot Size(sg.ft.): 13024.44 Owner: NEAL DAVID B&JOANNE Zoning:URA Applicant. James Roberts AT. 12 WHITE PINE DR Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTONMA01027 ISSUED ON:716100 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 Occu anc si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/6/00 0:00:00 992 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo