25A-128 (10) O4�tpTO
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT
(IicenseeJpermittee)
with a principal place of business/residence at:
J' (phone#)
(str=t/city/staiehip)
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)
( ) 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 Comparry/Policy Number) (Expiration Date)
f.
(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 ukhtioml sheet ifneo=uy to include moorn icon patn;ning to au 000tmctors)
Wcam 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 persons to do m&int�cowavction or repair work on a dwtWag of
DA morn than throe units is which the homeowner resides or on the grounds appurtenant therdo are not ge+om lly oo=dered to be
employaa under the workcrt ration Act(GL152,ss l(5)�application by a homeowner for a license or primer may evidence the
legal ctatiu of an employer under the Worker's C.ompematioa AcL
I unde sued that a.copy of this rtatement may be forwarded to the Departnxa2 of Industrial Aoeidao&offim of Imuraoce for the
coverage verification and that failure to secure average under socUon 25A of MOL 152 can lead to the imposition of criminal penalties
oonsistiag of a&ne of up to S1,500.00 and/or imptisoameni of up to one year and civil pemltia in tbe:form of a Stop Wok Or&-cad a
fine of S 100.00 a day against me
For deputmtw use o°ty
permit Number
Map#____--Lot#
Sig mb=of Li ernuttee
SECTION S-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: nno�nn Not Applicable ❑
Name of License Holder 6 6(2 3616
License Number
Address Expiration Date
l -0/.
Signature Telephone
.s _.._ Not Applicable ❑
Company Nana Registration Number
n �7 a�� �� �° 51 , -)/ 16
Address Expiration Date
MTelephone —00e
SECTION 10-WORKERS'COMPENSATION INSORANCE 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...... ❑
I MIA
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
CTIO _ E` O O Q D chec I a livable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 6 oz"XiL
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
.
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?
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
OWNERS;AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby au size J.� �MPT �1 b f/ IV6 I 7V, to act on
my be , in all matters relativetoo work authorized by this building permit applicatio .6 2 sle�
Signature of Owner Date
as Q�/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.
� N V1J
Print Name
4�� 6
Signatu of QwWRfAgent 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
IF YES, describe size, type and location:
U E C E ODW EN r mpton
Building rtment
2 St
JUN 2 7 ���Ro Oeet
Nor ham on, 14A 01060
Div" ll�trS����240 ax 413-587-1272
MrRT"t MA 1060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'A -SITE INFORMATION
1.1 Property Address: Thsection tone Ieted �ffce
Map 14o
done �� Y llirtic
"CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I �rkl,0 �� 6���
Name(Print) Current Mailing Address:
C Telephone
.signature `
2.2 Authorized Age 4.
5 HT P f? 12 � JC16 .s e 6,2_')
Names( rint) Current Mailing Address:
—0 I`� C)
Signature Telephone
SECTION 3—ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building (a) Building Permit fee
2. Electrical Mme' (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) v Check Number
This Section For Official Use Onl
Building Permit Number: Date Issued:
.�r'gnature:
Building Commissioner/Inspector of Buildings Date
BP-2001-11 18
GIs#: COMMONWEALTH OF MASSACHUSETTS
.r, ho:Block:25A- 128 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofin g BUILDING PERMIT
Permit# BP-2001-1118
Proiect# JS-2001-1968
Est. Cost: $841.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 19209.96 Owner: NIGROSH BARRY J&ELLEN EMERSO
Zoning.URB Applicant. DE Sheppard Roofing
AT. 21 BATES ST
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:61271010:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE GARAGE ROOF OVER EXISTING 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 signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 6/27/010:00:00 2232 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo