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m DEPARTMENT OF BUILDMG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CON PENSA'TZON INSURANCE 'MAVIT
(licensee/permitiee)
with a principal place of business/residence at:
(street/ci�/s1 a1rJa p)
do hereby certify, under the pains and penalties of pegury, 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)
( ) 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/Poticy 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 shwa ifnecc uy to include information pertaining to ell oortradors)
( I am a sole proprietor and have no one worli'ng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeoxroera who employ pcz to&ma�ccastructioo or repair work on a dwelling of
not mote than throe units in which ttx homoowner resides or oc the grounds gTuttenaot th=0 arc not Ccom'lly eoasidcrcd to be
employers under the worlca's o=vc=4oa Act(GL152,zs 1(5))�application by a homoow=for a Gecruc or pclmd may cvidcooc the
legal ctahu of an employer under the Workees Compomaiion Ad-
I undav-ind dirt a copy of this rt tcmcni may be forwarded to tho Dcpartnxat of Indio 01 Acrid-&Of 5 oc of Invuanos for the
coverage verification and that failure to secure covcnLp under scctioa 25A of MGL 152 can lad to the imposif.ion of crimintil penalties
eomisting of a.fine of up to S1,500.00 and/or imptisoanxn2 of up to one year and civil pcnaltia in thw form of a Stop Work Ord--and a
lino of 5100.00&.&Y against tan.
For dq=tD=W use only
ti Permit Number
NfhO_Lot#
Sr of Li rmr e
ti
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
�_
Name of License Holder : I�l�y �
License Number
LA
Address Expiration Date
Signature Telephone
w Not A pp licable El e� i
r
Company Name Re istration Number
Address Ex irati n Date
Telephone
SECTION 1`0 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...... ❑
O. W, �al. :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 108.3.5.1.
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
- s
SECTION 5- DESCRIPTION OF PROPOSED 1NORK(check,all:aDDlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 19 c3 t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
„ ddition to' tihu`sing; complee the following:oEww exisng. o
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
Sm CTION 7a 0WNER,AbTH0RIZATI0N TO BE:COMI'L1=TED WHEN
QWq!!R AGENT OR CONTRACTOR'APPLIES FQR BUILDING.PERMIT
I,
1G14 44 L .0 K& Z_ as Owner of the subject property
hereby authorize U to act on
my behalf,in all tters rela ' to work thorized by this 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
e
n
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
IF YES, describe size, type and location:
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--� of Northampton Statcis offer; .i '
ading Department
p s
2 Main Street
g 2001 Room 100
N rtha pton, MA 01060 T,wo�Sets of r o r
pho -587 1240 Fax 413-587.1272 Plod/Sitelas
060 -----
OF B1lILOINGINSPE Other Spec�fy� � �� � �
RT N 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:
Map nit
WT
.Zone Oyer ay Distrct �
r R p
EIm Sf. District v4 GB District
SECTION'2 - PROPERTY OWNERS H I P/AUTHORIZED,rAGENT
2.1 Owner of Record: Ij
Name(Prin4) Curr?�Mailing Address:
-
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
":�<6LN —1
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 = (I + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature
Building,Comrn�ss�anerflnspi;c#or of B,u<ildin&S Date ,
r
N AVE BP-2002-0069
GIS#: COMMONWEALTH OF MASSACHUSETTS
" �� '"= CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0069
Project# JS-2002-01 10
Est.Cost: $2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THOMAS FIL 131645
Lot Size(sq.ft.): 8799.12 Owner: DROZDAL CHARLES J TRUSTEE
Zoning Applicant. THOMAS F I L
AT. 60 SHERMAN AVE
Applicant Address: Phone: Insurance:
127 WEST ST (413) 584-3945
HADLEYMA01035 ISSUED ON.71191010:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/19/010:00:00 1031 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo