36-165 (2) SALES 100345
SHOW THIS NUMBR ON
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CUSTOMER ORDER DATE
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SIGNATURE AUTHORIZED TO AL
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
censer/permittee}
with a principal place of business/resideuce at:
2-1 061 K 01062 -a
_(phone#) .S '* C)
(Street/city/stave ip)
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:
Gamra.nce Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
,f
(Name of Contractor) (lasurancc Compauy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach • oml shed ifneocssuy to include information pertaining to all ooatm ors)
( 1 am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowocta who ccnploy pcaom to do mxmja ncc�wnstr=oa or rcpa it work on a dwelling of
not more than threo units is which the hoamwncr resides or oa the grounds appuiteaarmf thereto arc Dot gully 000skkrcd to be
emPloyrz3 under tho worker's.00mpcm4on Act(GL152,=1(5)),application by a homeowner for a Boca=or permit may evidcnoc the
legal o—, of an employer uoder the Workceg Compe ation ArL
I unda%t*nd thA a copy of this ctatemmt Day ha farww,,a to the Depeutmeat of IndusQial Acrid-&Oflioo of l--for tba
covaxge wnficatioo and that failure to seatre coverage under soaion 25A of MCIL 152 can lad to the impo oa of criminal penalties
oonustmgof a fine of up to S1,300.00 and/or imgrriso�of up to one year and civil pcaattia in the form of a Stop Work Ord--and a
fmo of s 100.00 a day agniasi rnc.
For&Pnta -W uio oaty
Permit Number
Map#-Lot#
,, Si of rmitt= ;Date
SEfT���B05 RUtr' ION SER1/ICS
8 1 Licensed Construction
Supervisor: Not Applicable 0
Name of License Holder : 3e5'5e t ` m-6- 1erm
CS C)77'-11C2
License Number
/1� /o/ Lgoo-?
Address Expiration D41e
AA. J,
Signa re Telephone
. _ - mss[ w•-�^ .,P""",e: - "`,.'' v- m'k '-!FL.
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIO�f 10=:WORKERS',COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25'C(6))
n
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
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[' Other [ ]
Brief Description of Proposed Work: 2 ry,I✓ ar- a 5 [-1 1'0&4 a ki-4 41
Alteration of existing bedroom Yes " No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes ✓ No
Plans Attached Roll ❑ - Sheet❑
ff Ne; h seid.oratlditioli ° w ezisfin housn com' letet e' followin`-:
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 O;R�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 me
Signa re of 0 r get Da
• t
f
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 ver been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis ry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
Y
B. Does the site contain a brook, body of water or wetlands. NO DO N'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
_-�.-- epartment
1 in Street
100
I North n, MA 01060
CC�holni 4T 58 0 Fax 413-587.1272
APPLQ `t JWEICT, A TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC -SITE INFORMATION
Thls section to`n'e compCeted py ce+
1.1 Property Address:
ft
c>P�c1LF- � l�e Zone � Ou 1a is# � d
Elm S ':Ristrict � CBG�s riot x-
t
._._.__. .
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P i t) Current Mailing Address:
Telephone
Si gnat
2.2 A thorized Agent:
Name(Print) Current Mailing Address:
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
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) ov, oo Check Number
This Section For Official Use Onl
BulldmgPermit'Number Date Issued: b'
Slgnature
dui dmgComrnfssi�?erAnd for of'BUIJ ir)gs. Date
*5 A'. 4 EAX, BP-2002-0421
GIs#: COMMONWEALTH OF MASSACHUSETTS
:Block: f`t5' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002-0421
Project# JS-2002-0635
Est. Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JESSE MONTGOMERY 077410
Lot Size(sq. ft.): 17424.00 Owner: LAFLEUR ROBERT E
Zoning: SR Applicant: Jesse Montgomery
AT. 795 FLORENCE RD
Applicant Address: Phone: Insurance:
46 Oak Street (413) 585-848Z_0
FLORENCEMA01062 ISSUED ON:10 118101 0:00:00
TO PERFORM THE FOLLOWING WORK R E PA I R ROTTED SIDING & TRIM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
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 10/18/010:00:00 1091 $25.00
212 Main Street, Phone(413) 587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo