36-201 9 6 �assarhttsctta
e
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S CONTENSATION MSURANCE t AVTT
(ltcensec/perinittec)
with a principal place of business/residence at:
� `�,r7
(street/city/stafr/rip)
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)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml slice ifnoccssuy to include infornution pertaining to all coatrattors)
(&,41--am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that v&Uc hoa=wncrz who employ persa=to do c,3-ic rn,�cou:�rrucrion cr tcpair ymik on a dwelling of
not more than three units in which the homoow ucr reside oc oa the grouadr appurtenant thereto arc not gcncrzlly ooandacd to be
employers under the worlca's ration Act(GLI52,=1(5))�,appLication by a hontcow=for a licrstse or permd may evidcaoe tho
legal status of an omployer undertho Workvet Comlpaualion Ate.
I undcz c d that a copy of this statemcot may bo fm waded to tho Dcpaitnx of I.&'utd d Acci&c Y Offioa of Inx-for the
covaige verification and that failure to secure ooverago coder soctioa 25A of MGL 152 can lead to tho imposition of crimia penalties
ooasistirtg of a fine of up to S 1,500.00 zrwor bnpiso of tip to one yrzr and civil pmsltia in the form of a Stop Work Ord and a
fine of S 100.00*.day against the
For&P-tm�u10 only
1
Permit Numtter
of U ermittee 2
SECTION 8—CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
yi/i,,.r'� ,✓f Est/
Name of License Holder : T
License Number
� r
Address Expiration Date
6,
',$ignature Telephone
I
. .r . � .w,. . . .C°nt A
MV Not licable ❑
9mRe i teredHomelmr ht actor , �` '„_M _.._n .. .�E ._.,s. ���__. _, pp
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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...... ❑
WARM; N
n€
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 108.3.51
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 buildinil permit.
As acting Construction Supervisor your presence on the fob 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 Sta e of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5 DESCRIPTION OF PROPOSED WORK'(check all le)
applicab
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing /
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet❑
s If New NO- fb"dditidri to°eicistiniZ housing;`compI te>th 10[ awing.
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
5 CTIOtV OWNER�UTHORIZATI01 IN,-TO BE COMPLgTED WHEN
0 ►N S A >=N O OON`f FACTOR APPLIES FOR>3UILt�ING PERMIT
� as Owner of the subject property
C
hereby authorize to act on
my behalf, in all matters relative to7, ork authorized by this building permit application.
Signature Owner Date
as Owner/Authorized Agent
hereby declare tha he statements and in ormation on the foregoing application are true and accurate, to the best of my
knowledge and bel ef.
Signed under the pains and penalties of perjury.
Print Name
Signature of Ownej'/ 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?
f,
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:
�..
i �:
i
City of Northampton Sta usoP :rrt .
RA artment ty L� tl Street 5e, e Sep'rA:ar
R 00 Wa errs l v
SCl am o , MA 01060 T> o Sets 5 c a " {,
°°jj((��
phone 24t13�87- Fax 413-587-1272 P►ot/Sltef?ta s „'
Other Specfy
+���MWCT�, AL+, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -'SITE INFORMATION
1.1 Property Address
This section to be completed by off cep
IN"A
Map Lot rtit
..
Zone j s Ovr1aD�strict
r Elm:St,Dist&t: C1 ric
fx-
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print Current Mailing Address:
""z Telephone
Signatu e
2.2 Authorized Agent: _
Name(PrAtf Current Mailing Address:
f
Signatur$ Telephone
SECTiO -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:
Date
dui(ding- ohnni stoner/Inspector`ofBuilding v. .._ .,
4 � y, BP-2002-0339
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categ-ory:roofing BUILDING PERMIT
Permit# BP-2002-0339
Project# JS-2002-0515
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq.ft.): 92347.20 Owner: WILINSKY CYNTHIA LAMY
Zoning: S Applicant. James Roberts
AT. 39 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:91271010:00:00
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. 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 9/27/010:00:00 1408 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo