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0
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE Ar,MAVIT
(li censee/permi tt ec)
with a principal place of business/residence at:
/lI-?, /9 /trae° fe+-) G . Q/y 2 (phone#)_ e 1 7 7j
(st=t/city/stalrlrip)
do hereby certify, under the pains and penalties of perjury, that
(I—K, am an employer providing the following worker's compensation coverage for my
employees working on this job:
Z4, jK
(Insurance Company) (Policy Number) (Expiration Date)
O 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) (Expimboa Date)
,,
(Name of Contractor) (Insurance Compmy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additi onil slxct if neccasary to include mforaut oa pertaiaing to all 0on.7actor3)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pleas-be nwarc that whilo homcowvas who employ pczr to do m-nia2�='I ru oa or rcpau work(Ma dwelling of
not mode than throe units m k�ch the homoowvcr r=dc3 oc on the gr0t D aprurtcnant thacto arc Dot&c=-Ally coc sidacd to be
cmploY—under the w0Ci 5 o=*c meim Act(GLI52,=1(5)),appticaflon by a homooww far a Uccase cc permit may cvidcnoc the
1e931 ctat"of an employee under the Woikcez Compeo Gon Act
I understand that a copy of thij axtl cnt may be forwarded to the Dcpertmasf of Industrial A=&—&Offioo of Insu —for the
coverage vaificatioa and that failure to s,==coverago uudcr section 25A of MGL 152 can lead to the imposition of criminal pcnali:es
consisting of a fine of up to S1,500.00 and/or imprisonmcat of up to one year and civil pcnaltia in the focm of it Stop Work Ord-:and a
f=of S 100.00 a day tgaitxst mc.
i' For&P-tr�uao only
Permit Number
MaI11 I,ot#
Signature of LiccnseelPermittce e
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction�Supervissor: Not Applicable ❑
Name of License Holder 3 e 0 7e-1 —?"/
License N mber
Address ExWation ate
Signature Telephone
u � +eR
° ,,g,,,�,; ,,� -- Not Applicable ❑
. akx, ,�n
Company Name Registration umb
Address Expiratio Dat
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25'C(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
SECTION 5 DESCRYPTION OF PROPOSED WORK(check alrapplica6le)
�... . ... . .,n,.. . �..r, .
New House T, ❑ Addition` \\ ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: A
5/1it. r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a�Jf New ho ise�and""or adtlition'to'exi"sting dousing,"'CO 01e1 A folLo`., I fik
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-OWNEW LITHORIZATION -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 OK�rr th e pains and altieess of perjury.
Print Name
Signature of Owner/Agent Dat
.a
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 Parkin 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:
A
� � orthampton °S
IS i Department
2 lain Street
p m 100 a
SE 3 2QQ(�rt on, MA 01060
hone 413.5 7.1 40 Fax 413-587-1272 Rti "
DEPT OF 81111 DING INSPECTIDNS
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Zone Oirerlay�District€€
Elm St. District CB D!'Wict°
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ckG(- 14 e- C) 0 [ e
Name(Print) Current Mailing Address:
Telephone �) S
Signature fJ
2.2 Authorized Agent:
Name(Print) / Current Mail g 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) Check Number
.This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
90l� ff'm BP-2003-0221
GIs#: COMMONWEALTH OF MASSACHUSETTS
36�I� t CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category._ BUILDING PERMIT
Permit# BP-2003-0221
Project# JS-2003-0397
Est. Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sg. ft.): 258746.40 Owner: DOLE CHARLES S&ELINOR L
Zoning: SR Applicant: RCI ROOFING
AT. 908 BURTS PIT RD
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON.913102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ST R I P & S H I N G L E ROO F
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 9/3/02 0:00:00 607 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo