25A-127 (6) ttAM P�0
��. �fl Crz�r laf ��z:�Eltt»t�rt>;Iil -
as �ltssarhttsrcca'
m DEPARTMENT OF BUILDITjG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y ,`
WORKER'S COMPENSATION INSUIU,NCI; AFFIDAVIT
(h CCIlSCLJperml tiS)
with a principal place of businesslresidenee at:
(stre--t/city/statr/rip) —--
do hereby eel-tit',, under the pains and penalties of pef;rlry drat:
O I �mn an cmployer providing the following v;orker's compensation coverage for r1y
employees wol--ing on this job:
(Insurattc Conaisrny) (Pohry Number) (F_xpimtion D2te)
O i ni a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's cornncnsa;ion policies:
(Nam-, of Contractor) (Insuranct Compauy/Pohcy (Expiration Date)
(NaIne of Contractor) (Insurance Company/Policy Number) (Espir-non Date)
(Name of Contractor) (Insurance Comp�n)/Policy MIMI--x l) (Expim6on Date)
--------------------- ----
(Nalne of Contractor) (Insurance Comp_my/Policy Numb-:r) (Expir<:tion Date)
(atla�i uijitiocul t.`rcd i£n<cciviy t.�i_x}ude iafoctnaZ oa pataiaing to all a Ilractof l)
( I aln it sole proprietor and have no one working for me-
( ) I am a home owner performing alt the work myself.
NOTE:plcasc be nwraz that w1ii1c homco A-I-,=who cruploy pazoas to cS c n c;ancc aY. n cs Tcpa r vote on a dNvclling of
not mote thm ti:rco units in wEdi the homrouncr ra des ar on:be grounc s appuctcn ai thacto ere oc<Eax wily ooasidcral to be
employes undr_r the wocktx's c,,r c aticcm Act application by n hoc:ncow-cxr for a l:cai5e cc permit=y nidcnoe the
1cgal giau"of an empI0yor undor tho Worlcolt Cotnpomatio ALt
I undcrsttnd that a copy of thin rz trr.wit m„y bo focwadaJ to the Dqt tn�A of In Listriel A,66,,tf Ofuoo of Irn-for tho
coverage va-ificadon and that fail=to secure oovcrngo undcr section 25A of MOIL 152 can lr.,.d to the imposition of crimiaal Penalties
ooc*sting of a fine of up to S1,500.00 and/or ir� of up to ow yrar and civil pcanitia in tix form of a Stop Work.Or&r and a
fino of 5100.00 a day a&Iinat tir
Forrtnridal use ccily
VA� Permit Nttmber-
_-�1—U,j NfaP;l 1.ot 4
Sign<-';tore of Lic=sc&Pernut2ce Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ G
Name of License Holder :%4\2S4 716A-1-
License Number �-
-2) a. h� S � `' a� Cn— ?-I — 0 S
Ad ress 1 Expiration Date
io-
Sig ature Telephone
9' Registered Home`Imro`vement<Co"ntra'ctor , „, N t Applicable ❑
C)S � r 14 S7 t1 8'4 y
Company Name Registration Number
_ o y�ss_ Cam- C S
Address i Expiration Date
Telephones-1�3 S d3c1�
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...... ❑
11.�., o"ine Owne EXemlption
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 buildinlz 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 pen-nit 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- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: f - v{�/ l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
,Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet C
sa. If New house and or"addit'ion to'existing housing, complete'the folloWin :
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 Fnergy 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
i -
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, _ y` �r__ �`\ , as Owner of the subject property
I hereby authorize � CIA) Q to act on
my behalf, in all ma t rs,re ative to work authorized by this building permit application.
/11 '1 014
I 4SWOreof Owner ate
as Owner/Authorized Agent
hereby declare al e 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.
A
Print Na e
91c��3LA - �'
Signature of Owner/Agen Date
.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 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:
s
w �
----- �.of Northampton
ilding Department Curb tlD,ivew t ' �r•91�a�4iP"�°���lar��h,im � � �
l� MxD 3
1.2 Main Street SewerfSep rcA
r .Room 100 Mr )We Avaala 1r;
1 , y t i �3r
Ngf ial�npton, MA 01060 Two
phone 413 587 1240 Fax 413-587-1272 Plot`"%S to Plans ��
Other.Specif}%
a
AP-PLICATrON f0 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION--� _
Address:
This section to be completed b e
y offic
1.1 Property A ,
Map 'Lot
Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner-of Record:
Nur
Name(Print) ng Address.
— --- M— -- --
1 Telephone
Signature --
2.2 Authorized Agent_
Name(Print) Current Mailing Address:
Signature Telephone _
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a) Building Permit Fee'
o�r h
r2. 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
25 BATES ST' BP-2004-1302
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 127 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1302
Project# JS-2004-1961
Est. Cost: $1700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zoning.URB Applicant: Robert Thibodo
AT. 25 BATES ST
Applicant Address: Phone: Insurance:
P 0 Box 201 (413) 586-0391
NORTHAMPTON MAO 1061 ISSUED ON:6122104 0:00:00
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. 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:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/22/04 0:00:00 2143 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo