25A-074 (3) OQ�tPTO
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee}
with a principal.place of business/residence at:
/Sll PALLF 7 (phone#) A�ZISZQQ
(&ti=t/city/§tatd2ip)
do hereby certify, under the pains and penalties of perjury, that:
�kl am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Polity Number (Expiration ate)
( ) I am a sole prietor, 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 Numbcr) (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 additiomr sheet ifnecens y to iric3uric information pauiaing to all ooatrado:a)
( ) 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 aware that while homeowners who employ pc=m to do ma bats a�ooasuvctioa or repair work on a dwelling of
not more than throe units is which the homeowner resides or oa the grounds appurtenant thereto are not gaxrally ooandard to be
employas under the workerAs oompeusatioa Act(GL152,ss 1(5))�application by a homeowner for a license cc permit may evideaoe the
legal stahra of en employer under the Workers Compensation Ad.
I understand the a copy of this date may be f%,%wded to the Dcpatia of LxkL rial A=rm&0!&oe of Inunnoe for the
oovesxge vmficatioa and that failure to aocure coverage under section 25A of MGL 152 can kad to the impositioa of criminal penakics
oonsistiag of a foe of up to S 1,500.00 andfor impriso�of up to aria year and civil penalties is the form of a Stop Work Order and a
firm of S100.00 a day against mr-
l, For dgs�use only
permit Number
.....% i' Map#-Lot#
si of LicenseelPe 'ttee e
Mks---
® emu'♦,=..�-_�r..:s::.�.-'�.Yf+:•.�
SECTION!8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
CS 07� ,Ct
-If) A �� (-� - 2
Name of License Holder
License Nu ber
D4� (r-7 C', _ooh
Address Expiration bate
2
Signature Telephone
"yn
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...... ❑
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 buildine 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
ECTI{1N - QESCft1ETJ6N F P t3POS ' abl'
New House ❑ Addition ❑ Replacemen 1 ws Alteration(sX❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: 21 s- 12--)JV) 00 '10 %K:F,
Alteration of existing bedroom Yes_ �� No Adding new bedroom Yes ✓ No
Attached Narrative 0 Renovating unfinished basement Yes _�No
Plans Attached Roll 0 - Sheet❑
s ".
a. Use of building : One Family �. Two Family Other
I
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? 01'�
d. Proposed Square footage of new construction. Dimensions
e. Number of stories. 2
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 _-�ZNo. Is construction within 100 yr. floodplain Yes No
f
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? t,� Yes No .
I. Septic Tank City Sewer_l, Private well City water Supply
SECTION 7a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPL tE$ FOR'BUILDING PERMIT
I, �/'� as Owner of the subject property
hereby authorize y ' I C-j4AC4-- to act on
my behalf, in all matters relative to work authorized by t building permit application.
/�
Signature of Owner Date
I, 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
Signature of Owner/Agent Date
A.
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
D NIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front 1-Z
Side L: R: L: R:
Rear (Z
Building Height 2�
Bldg.Square Footage i %
Open Space Footage %
(Lot area minus bldg&paved
parking)
i
#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 _ �Z _ 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:
To � UIR
3 � City of Northampton
Building Department
8�� firasE c1yt1N�
212 Main Room 100eet
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: hi lea Y "
' y " r 7
rr rrr r. ' v i4
f n
Tait str
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D�t
SECTION 2-PROPERTY OWNERSH'IPCAUTHORIZED AGENT
2.1 Owner of Record:
` A
Name(Print) Current MMa_illiyng_Address:
Telephone
Signature
2.2 Authorized Agent: !� ,, (� `z
Name(Print) Current Mailing Address: `
Signatur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COS`T5
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
���- A 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'Onl
Building Permit Number: bate Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0491
APPLICANT/CONTACT PERSON MICHAEL MOORE
ADDRESS/PHONE 1321 BRADLEY RD (413)782-3200
PROPERTY LOCATION 386 BRIDGE ST
MAP 25A PARCEL 074 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: UPDATE BATHROOM,REPAIRS&SOME WINDOWS
New Construction
Non Structural interior renovations
Addition to Existine
Accessory Structure
Building Plans Included:
Owner/Statement or License 077024
3 sets of Plans/Plot Plan
VLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
pproved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § _w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Co on Permit from CB Architecture Committee
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
386 BRIDGE ST BP-2001-0491
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-074 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0491
Project# JS-2001-0848
Est.Cost:$9600.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL MOORE 077024
Lot Size(sq.ft.): 6011 .28 Owner: KENNEDY CHRISTOPHER A&DENISE
Zoning:URB Applicant. MICHAEL M OO RE
AT. 386 BRIDGE ST
Applicant Address: Phone: Insurance:
1321 BRADLEY RD (413) 782-3200 Workers
Compensation
SPRINGFIELDMA01 118 ISSUED ON.11 117100 0:00.00
TO PERFORM THE FOLLOWING WORK.-UPDATE BATHROOM, REPAIRS & SOME
WINDOWS
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 11/17/00 0:00:00 4787 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo