25C-003 �0
'C�MPT
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORTCER'S COMPENSATION INSURANCE AFFIDAM
de"O';I� / �0
(liceusecJpermittee)
with a principal place of business/residence at:
'Q �k /��' ZeMI13'' Wit. �1r�J'�� (phone#)
(streei/city/stafe/rip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the follolvving 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/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poticy Number) (Expiration Date)
(Name of Contactor) Gnsurance Compaay/Policy Number) (FaTp ration Dale)
(Name of Contractor) (Insurance Compary/Policy Number) (Expiration Date)
(attach additioml slxct if ntc v to ioOudc infonnstioa pertaining to ell oou-Mcton)
(�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 hoc cowjxra who employ pcaam to do m j�construction or repair work on a dwelling of
not mcct then throe units in utsich tlx homeosAvcr residd or ou the prouodr appurtcnaat thac to arc not ga)a-jily oocnidcrcd to be
employms unda the worker's ration Act(GL152,ss 1(5)�application by a homooRna for a lia>zsc a permh may cvi&noc the
legal ctahra of an employer under the workcez compao5.& a Art
I uaderst,ind ttvt a copy of this tiat—at may bo forwarded to tho Dcpaxt=rd of Loduslrial Aocidcn&Oftioo of L—wico for the
eovaago vaif-calioa and th9 fad=to acatre oovccMgo under soctioa 25A of MGL 152 can lead to the imposition of criminal penalties
ooatistiag of a fine up to S 1,500.00 and/or impriso=Cx A of up to one year end civil penzltia in dr form of a Stop Work Order and a
f=of 51oo.00 a hay tgainst me
Foe depx'tirr�uio Daly
Permit Number
Si J / d WP# Lot tt
of t ermittce e
SECilION38CONSTRU CTION:SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable ❑
Name of License Holder _7/
Licens Nu ber
ivy
lo
Address Expiration Date
Signat e IV Telephone
r. Not Applicable ❑
,QALe
Company Nam Registra 'on mber
Address Expiration Date
Telephone 's7v—,5TId
SECTION 10-WORKERS'_COMPENSATION INSURANCE AFFIDAVIT(M.GL. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affid
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)famili,
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act,,
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,
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 D SCRIPTIWOFiPROPOSE61WORK check all a licable ,
-133I rhx F MkAN A Y b 4 3 '•c I d i 31 .LP" ,k' ,L,��,}+ '
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: %�� t��� :ti d� ,�. -��' PPS / in. " e
J 4-01
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
a��a:�IfNeho `" a°`nd�`or"' a" fiiition'_to�iristin'g�housln�,�corripiee` th���f�llow.In :
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
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
ONYNERSdAGEN7 OR CONTR'ACT:OR APPLIES FOR,,,BUILD1 , G PERMIT
Q 4; as Owner of the subject prope
hereby authorize to ac
m half, in all matters rela4ve to work autho zed by this building permit application.
4& W Signature of Owner Date
r ,r�/F as Owner/Authorized Agent
hereby decl that the st ements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed and r the pain and enalties of perjury.
P�
Print Na
Signature of ner/AgeO Date
I �
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_V� 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:
t
i . C °oif Northampton
�,$tiildibg Department
21`2 Main Street
MAR 1 $ 2003 Room 100 vy use
Northampton, MA 01060 ens o
ph" 413.587 1240 Fax 413.587-1272 l?iotfSite� � a _.
G ; OthWrSpec�.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be('corn bete y fftce
1.1 Property Address:
`f� P
Ma totem
�—,
Zone,
OVerlaybis#riot
YP.
Elm St. District CB D strict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N e tint) Current Mailing Address:
p r'?
Telephone
Signature
2.2 Aut rized A ent:
Name(Pri t Current Mailing Address:
Signatur 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 = (1 + 2 + 3 + 4 + 5)
,'J ', Check Number ''r
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of!Buildings Date
T
ax
BP-2003-0758
GIS#: 4 COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0758
Project# JS-2003-1249
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Craig Marney 102112
Lot Size(sy.ft.): 9191.16 Owner: SALVATORE FRANK V&MURALEE A
Zoning:URB Applicant: Craig Marney
AT. 19 WOODMONT RD
Applicant Address: Phone: Insurance:
P O Box 128 (413) 586-5512
LEEDSMA01053 ISSUED ON:3119103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 3/19/03 0:00:00 3400 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo