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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKEWS COMPENSATION INSURANCE AFFIDAVrr
(ii censee/Permi tLee}
with a principal plaice of business/residence at:
(street/city/stale/zip)
do hereby certify, under the pains and penalties of perjury, 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)
/CI am a sole proprietor, general contractor o homeowner(cir le one) and have hired
contractors listed below who have the following compensation policies:
9"Z '0--e�'� 11 1
(Name of Contractor) (Insurance Company/Policy Number) (II)Tiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiond shod ifnwassary to ia'"hrde information pertaining to all ooatradors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awue that whilo homeowners who employ pcnons to do maiatrnance,wmtructioa or repair work on a dweUing of
not more than throe units is which the homeowner resides or on the grounds appurtenartt thereto arc not goowally considered to be
employers under the worker's o=p=&4oa Ad(GL152,ss 1(5)),application by a homeowner for a license or permit may evid—the
legal gutua of an employer under the Wodra a.companution Ad.
I underdaad that a copy of this statemeat may be fm warded to tho DeQarmscut of Industrial Aocidaa&Of ioc of Insurance for the
coverage verification and that failure to&==cowraga under suction 25A of MGL 152 can lead to the imposition of airmen!ptwffics
consisting of a fine of up to S1,500.00 and/or im}ttiso�of up to one yrar and civil penalties in the form of a Stop Work Order and a
firm of S 100.00 a day against me.
gPermit t wr tal use only
Number
Lot#
Si are of LicenseelPermittee
SECTION 8-CONSTRUCTION SERVICES
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
SECTION 10-WORKERS' COMPENSATION'INSURANCE AFFIDAVIT(M.G.L.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 the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
s
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.
omeowner Signature Q,
OE PR c applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: 'Q-e b-r � 0 r w'Nf'
Alteration of existing bedroom Yes //No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes 'No
Plans Attached Roll 0 - Sheet❑
Y.
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 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
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
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
GU
Signature of Own gent 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:
JP�
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
SECTION 1-SITE INFORMATION
1,1 Property Address:
�
j 3 i
j i sk d r
/f � YI� i r
Zone 0it
.v
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Pint) Current Mailing Address:
Telephone
Signature C7
2.2 Authorized Agent:
' d2 V e ,4. 7-e A eoa,451,4.
Name(Print) Current Mailing Address:
Signature Telephone
SECTION ESTIMATED CONSTRUCTION CASTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cast of
Construction,from, 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) l q G s—, c a Check Number
This Section F Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissionerlinspector of 15411d ngs pate
264 BROOKSIDE CIR BP-2001-0298
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 36- 135 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
CategM: chimney ebuild BUILDING PERMIT
Permit# BP-2001-0298
Project# JS-2001-0477
Est.Cost:$1465.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor., License:
Use Group:
Lot Size(sg. ft.): 15768.72 Owner. ZEITLER BRUCE A&LINDA J
Zoning:URA Applicant, BRUCE A & LINDA J
AT. 264 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
264 BROOKSIDE CIR (413) 584-4252 ()
FLORENCEMA01062 ISSUED ON.9119100 0.00:00
TO PERFORM THE FOLLOWING WORK:REBUILD CHIMNEY
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 9/19/00 0:00:00 4209 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo