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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE A TMAVIT
(licenser/permittee)
with a principal place of business/residence at:
(phone#)
(street/city/statr/ap)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the folio,,ving worker's compensation policies:
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Eniration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml Sheet if neccuary to include infoemifioc pertaining to all ooatrad rs)
(16 am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:picase be aware that whilo homcowvm who employ per o to do m �construction or repair work on a dwelling of
not more than three units in which the homeowner resides a oa the grounds appurtenant thereto arc Dot gcocrally oowidcrcd to be
entploycra under the wmictra comp ns4on Act(GL15U31(5)),application by a homeowner for a Uo=m or permit may cvidcaoe the
legs!d—, of an employer under the Wodcoea Compomation AcL
I uadcrstaad thst a copy of this ctatemcns maybe forwarded to the Dcpartnro2 of In&i .l Acci&�&OfSoo of 1—m"aoe for the
covenx verification and that fail=to s%xzue covcrago under Section 25A of MGL 152 can lad to the imposition of cr mina]penali cs
oomisiing of a fine of up to S 1,500.00 andlor imprisoumad of up to one year and evil penalties in the form of a Stop W ocic Otda and a
fine of S 100.00 a day against ttx
For dcpsrtmalw use only
/)4rl, t Nttmbe� Lot#
' Si
01 LiC=scelPermittee :
SECTION 8=:CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : / l�c' 636 6
License Number
Address Expirat' n Date
G
Signature Telephon
r�
PP
Not Applicable ❑
Company Name Registration Number
/ 1IGS �%- 7 ni �i7 DIGS 7 /-z-
Address Expirati nDate
Telephone 5�-,-F Gl?d
SECTI04;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...... ❑
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
SECTI'ON � DES"CRIP TINOFjPROPOSED'WORK' checkalFa `licable
u. 4 �,. „ . _7�N�«.���,� „ .
3 rah,Ia xV3 �1"0. .
x
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 No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
s If New �o lse a°itl r acklit16hLtdXXi' tinit'Ad' sihI complete the'if ol`lawin :
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
0WNERS_AGENT .R CO pClOR=APPLIES FOR.BUILbING PERMIT
as Owner of the subject property
hereby authorizel� to act on
my behaif, in all matters relativ to work authorized by this building permit Gpplication.
Signature of Owner Date
as Owner/Autho ed Age
hereby declare that the state ents and information on the foregoing application are true and accurate, to the best o
knowledge and belief.
Signed under the pains and penalties of perjury.
0 �� t$ZP
Print Name
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
1 IF YES, describe size, type and location:
r` r
City of Northampton
�I Department
ain Street
Jom 100 .
Mort, ton, MA 01060 e"
phone 413 240 Fax 413.587-1272 0 #
DEr1
APPLICA TO ISO
M RUC , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1--SITE INFORMATION
This sectlon`tobecompleted by office
1.1 Property Address: k
Map �a L�ot.
l�
ma �� a 'A
EIm:St Dis#rict" `. CB Disirict y
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
N me(Print Current Mailing Address:
- -16ephone ' --
C Si ature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature r Telephone
SECTION..-3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
co eted 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) L Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner%inspector of Buildings Date;"
I
BP-2003-0224
GIS#: COMMONWEALTH OF MASSACHUSETTS
fi CITY OF NORTHAMPTON
Lot: -001
Permit: B u i I d i nl?
Category: BUILDING PERMIT
Permit# BP-2003-0224
Project# JS-2003.0399
Est. Cost: $2999.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 35719.20 Owner: GURN DENNIS B &JANET C
Zoning_ SR Applicant: DE Shepard Roofing
AT. 17 DIAMOND CT
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:913102 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING 1 LAYER
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/3/02 0:00:00 669 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo