25C-035 (3) MAR-08-2002 14:34 JQNES TOWN COUNTRY REALTY 1 413 549 7632 P.01-1 /01
� w
R.C.1 ROOFING
40 MAIN!AVE.
P.O. BOX 309
EASTHAMPTON, MA 01027-0309 m '�TINATE
1) 4g AX 43BV4
3i4\02
CAMEO
n:
CLAVpLTfiB boo fdjkDjw air, CEt[cxe TMAMN
200 TATlNas 3T am Umb:
ht'd!lm'L'm 01002 ;3 25 WORTUPS ,AV9
NGft:'tiupx'm'm 01060
JCPbPhW*'. 575 "7141
AM WSCAWWN
SUT-
OW MAL!'/SAID NW..DW
COATUACT AS/1'P 11t-LD D 2 9 T 1.50 BARS Fl".
kin t�lAid Jab eH►nets
TSAµ!F]F OrV11[!�
aoM pRftJR ro#riutr ToW�d�
7a a SlF�9M C0 4GrIt7N Job e-*& "1000.00
!'#�ifaTiL4TgN tt�20d
"NaRAb,to,mm :MFt bbdf AddllQ/fild
i�N6?ltlbJG'Y�QM�it7ti►Nit�OT�ii�
71- EN7
200 Triangle Street Claudette. Boudreau
Arnheru,MA 41642 RFALTr??R'CR.'
(413),549-3700 Lt.17 b udreau%ones•tc.cam
J Oufs!de MA:!80V 343-06t;8 s .,.,,.
TOTAL P.01
Grff� of Wart4aixV aii r
g B �lasaxc[ittsrtta'
e -
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 'may '�•�
WORKER'S COMPENSATION INSURANCE A.l'F MAVIT
(licen_SCeJP 1kW)
with a principal place of business/residence at:
yd mgt n Ca-qtr- _ �ac\ rcy�3�cj(\ , V%m, OtOZI (phone#0/�s 7_7 'A IS
(streeUCRy/s Id2ip) - -
do hereby certify, under the pains and penalties of perjury, that:
(vKI am an employer providing the following worker's compensation coverage for my
employees working on this job:
\ t( n 4", �,Jc\ -3IS-3t'1►24 otl I0-5"- o2,
ce 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)
t.
(Name of Contractor) (Insurance Compairy/Policy Number) (Expiration Date)
(Name of Contmctor) (Insurance Compauy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E�iration Date)
(attach additiooal sheet if noccssary to include information pertaining to art omt=t0n)
( ) I am a sole proprietor and have no one worsting for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who rsnplay pasom to do miajM�comtrnaion or repair work on a dweniag of
not mote thsn throe units in which the homeowner raid=oc on the grounQs appurtcuant thereto arc cot generally oomidacd to be
employers under the worker's oompensation Art(GL152,ss 1(5))�,application by a homcow ncr for a license or permit may evidence the
legal rtatm of an amployer uoderthe Workc?t C.ompomation Act.
I understand that a copy of tbia uatemeoi may ba forwarded to tbo Depwt=cd of 1a,&strial Accident,'OfSoo of Imrusoee for tba
covcrxgo wrificstioa and that failure to town covcngo under section 25A of MOL 152 can Icad to tba imposition of aimin sl penalties
oomi ding of a fine of up to S 1,500.00 and/or imprison of up to one year end civil penahie s in tbo form of a stop Work order and a
fum of s 100.00 a day tgturut me.
For d tone only
Permit Number
Nfap4 Lot#
Sitmatum of l.iri-ne fPt�rmitfrt. _ --- WEY
s
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder �\ � —' 5� 'v
License Number
LAO GIA n . (>16Z7 Q
Address Expiration Date
�yi3\ 67-
Signature Te ephone
A r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTN (JWO KERS' COMP ENSATION4INSURANGEgAFFIDAVIT�tM G L
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
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)familie
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(:
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
.�. r Ila m. a
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: ell CIO�__7
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet 0
s I ' oiyn Ne� oe o � I on o a tstin in f f M w
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
PONT
�LETED WHEN
R 11,1�ING P�t ,
o�� ��C,.� as Owner of the subject proper
hereby authorize q, to act
my behalf, in all matters relative to work authorized by this-lbuilding permit application.
Signature of Owner Date
' 100gkV_Xa as.Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application-,dre true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
,(- ` k
PrintNin�
<r
Signature of Owner/Agent 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:
r.7
it f Northam ton
c i�Cj�ONS y p
p��t A� oto�o Build ng Department
N,,R�wA", a►�, 212 Main Street
Room 100
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
S�E�'T10.N�1.S�IT,���N�,F0�1111'q�lQN;r°
1.1 Property Address: s"sc i 'to tiea eted f'a
2-3 - 2-5
/j 0 k Ol00
:ras 4�i','•c_ti.,dw.� .. .,.5 uT a'esx'srs Ar +,.,.
SEGTIONi = PROPERTY OWfNER,SHIP/AUTHO 21ZEf)AGENT
2.1 Owner of Record:
Name(Print) Curr q nt Mailing A ress:
Telephone
Signature
2.2 Authorized Agent:
ox
YO �Qk .�O 1 ��n���il .jMg.. eybZ7
Name(Print) Current Mailing Address
(u Q���"� 7 y 77S
Signature llephone
ECTI 3= E�1'IMA D: �R Cllr h > I7+
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant s:
1. Building (a)'Building'Permif'Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = G + 2 + 3 + 4 + 5) Check,Number
Tahls,'Se,!L' iN or OfficiaL.Use'Onl
BuIldingPe�rm[ilumber Date'Issued:
ELI - r T7 u t ;
5 gn tare ? uz�' a n ail.. 5
pgiCo !$ r lf! p. #ar of.l ! g' �d- Date
23 NORTHERN AVE BP-2002.0762
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: �5C-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002-0762
Project# JS-2002-1266
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sg. ft.): 5009.40 Owner: BOUDREAU CLAUDETTE
Zoning:URB Applicant: RCI ROOFING
AT. 23 NORTHERN AVE
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027.0309 ISSUED ON:3111102 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/11/02 0:00:00 2476 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo