36-126 O O ( �
(riff of 'No fllullipfoil - —_-
g6 Hlaos itch nsctIo —
DEPARTMENT OP BUILDMIG INSPECTIONS
212 Alain Strect ' Municipal Building
?Northampton, Macs. 01060
WORICER'S COMPENSA'T'ION INSURANCE AFFMAN'Tr
i
(liccnsce/permitux)
\vIth a principal place of businesslresidence at:
(phone;')
do hereby certif)r, under the pains and penalties of perjury, thzt
O I am an employer providing the following worker's compensation coverage for Inv
etuployces wonting on this job
(Insurance Coar�ny) — (Polio:?`umlxr) --- FEx-pinion Date)
( ) I am a sole pr�belo\y, eneral contractor or homeowner (circle one) znd have hired
the contractors liswho hzve the following worker's compensation policies:
(Name of Contractor) (lnsslmnc Date)
(Name of Contractor) (lnsumncc Cotnpauyf•Pok—y ,iumt-zr) (Expir-non Dale)
(Name of Contracto,) (Insuranc: Compan}•/Pouq- Number) (Bpiraaoa Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attu�additiood shod if noccs.ir}'to incuck iafx=.!ioO pcstaioi w till ooa7n ,)
(y� I am a sole proprietor and have no one worizng for me.
( ) I am a home owner performing aH the work myself.
NOTE:plczsc be awarc tlui w1Llo bomcor;um who crnplay pcz-L=co do M...MIacc coca=%,loo or rtpair work oo.d-v1hn&of
not mocc thn d ruo unit,in wt icb 6c bomoowncr rcido o<oa the goundr appurtcnsni tbcCLO art Do(gcncnlry oocr dcrod to be
employm under the-oz h oar>pcasztioq Aot(GL152-"1(5)�appLL=6aa by a bomcoava fax e bccax cc permit tnay cvidco-tl`C
Ieffil ct.cau of an amployoc under d3 WOCk4et Compooaat Ad
- I undcsiand thst.a copy of this ruin mcut ovy bo focwnrded to tbo Dopuumr of lndzcs: d Aoodca&OfLoo of lmur•oco for the
oovcragc vtriGcitioo and that L•iltuc to acatrc covansc undcs souion 25 A of I.toL 152 m lud to tbo impasiiioa of criminsl pcmltia
00miati328 of a fine of up to S 1500.00-I NCX i=ntyoon>�of up to one year end civil pao hia in Sc form of a Stop Work Ordcr and a
fim o(:S 100.00 a day egaiwa me
For&p In r,:. —oo7y
Pc=t Number _
�� , S�•3�1 Map.". _ Lot� ---
Sipiahtrc of LtccliscrlPctTruttcc — o e —
SECTION r8 -CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� � lr.``.,. Not Applicable ❑
Company Name Registrak Number
Address Expiration bafe
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6))
Workers Compensation Insurance affidavit must be completed and submittPri with this annliratinn Faihirp to nrovidp this, Affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
�. W1, xn�� tearm ton .
The current ""
exemption for homeowners was extended to include O ies
P — ��
and to allow such homeowner to engage an individual for hire who di is
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on N ` -e
is,or is intended to be,a one or two family dwelling, attached or detE
structures. A person who constructs more than one home in a two
Such"homeowner"shall submit to the Building Official, on a form a e
responsible for all such work performed under the building per
As acting Construction Supervisor your presence on the job site wi
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
ECTION'5- DES' PTIO OF`PROPOSED WORK(check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding N Other [ ]
Brief Description of Proposed Work: 3166tc<'__^D V.r"A to
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a, If N w h ,an `or addition WeiWing hoysing. complete the f Ilowin
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
CLQf 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.
J L
Signa 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 {1\ \\
Signature of Owner/Agent 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 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 tus of P
Building Department Curt C1 erit y �a �
212 Main Street S uafalt` X s „ y�'
Room 100
Northampton, MA 01060 its o�zStrucnsz
phone 413-587-1240 Fax 413-587-1272lte Pla a n " F e
r
3111 Spe
y I
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
\
3 e Cie C�CZ`� Map Lot y t�° Unit
zone I A Overlay District
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
i ture
2 Authorized Agent:
Name(Print) Current Mailing Address:
(�\ v
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
L
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
Building'Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
263 BROOKSIDE CIR BP-2000-0982
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV-Block: 36- 126 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:vinyl siding BUILDING PERMIT
Permit# BP-2000-0982
Project JS-2000-1788
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KURT STAEB 127236
Lot Size(sq. ft.): 22651 .20 Owner: BERGERON DIANE R
Zoning:URA Applicant. KURT STAEB
AT. 263 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
2115 BAPTIST HILL RD (413) 283-6983
PALMERMA01069 ISSUED ON.5 14100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 5/4/00 0:00:00 2818 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo