25C-057 (4) a `E aTtL) of 'No tljamptoil
9 � E 3iasanchncctla —_'�
o DEPARTMENT OP BUILDING INSPECTION'S —'
212 Mam Strect ' Municipal Building
Northampton, Mass. 01060
wq C1,IZ'S COlI DENS ON INSURANCE AFITDAVIT
(liccuscc/Ix:rrr>;ttco) _ --_
\vith a principal place of business/resid"VII/lIcc at
(SU-C i- ity/statcJZi p)
do hereby certify, under the pains and penalties of perjury, :hat
( ) I cirri an employer providing the following workcrJs compcnsZLm covermye For my
etuployccs worming on dlis job
(Iasu_ --n= Comdr iv) (PeLic: `unabcr) --- - (r ,pir-azior, Daze)
( ) I am a sole proprietor, general c,0DU-actor or homeowner (ci:cie one) and have hired
the contractors Listed below who have the follo\vinQ worker's cOMDe11 2tion pckles:
(Ntlme Oi CO! '.cw-) (In-ur-anc'z Coinpaily/-1 GL c-r N=b--r) 11l1C)
(Name of Comactor) (Insurance Company/Police Numcrr) (ExpUZoon Date)
(Name of Contractor) (Iasuranc Compauy/PoUq- Number) (Expimaon Date)
(Name of Contractor) (Lasurmcc Compauy/Pohcy Number) (Expir-ouon Date)
(attaG}]addi:iccal r'_�cct ilocccsz� to mctuc�informiaoo Pc ain to.0
�am a sole proprietor and have no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE:PIS lx awzre tht u{ Jc 6eazvcrs ubo employ pc zom to do cis r�oo c c av .ark oo&d..c1L of
ON more th n tt L7arJ in"-bn the t omoo.vcr rrsido«oa the pour:,zapu�the eo coo Qa1iy occ ..d_cd to be
carploym unr'c the��kri's a�afico�(GLl S2Ss I(5)�appliczijon by o homnowvcr far c Iir.�__a Pcnnrt rz::y cvidcnoc the
Icg�J ctnnu of cn�loyer under dto Workolc Coo?pomei�oo rid
[undasinnd that a Dopy of lhu etat®crst m.y bo fog-.xnrdnd to tba pc�utmea¢of ln�irri el AnoderzC�Offioo of ln�u�noo foe the
covcr Se vmGeutioo and ttw L-Lm to toauc`covcm- tnodcr soc t on 25A of N(GL 152 can Iced to the LcapOsaioa of almiasl Pczxltia
oomisting of a riot of up to S1,300.00 arYdlcx i>�� of up to ooc year end civil pcnLhio io 6c form of n Stay Work OT`dc end a
rim o(S I00.00 a agaiasl tnc
For dc�.rtrr�=�uac Drily
pcmT t Number _
�� ar
Sign urr of Li M-6ttcc e
SECTION$-CONSTRUCTION,SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number�������
Addre Expiration Date
Signature Telephone
W1 ,11MARM, Hp Not Xp�plicable ❑
Company Name Registration Number
Address E anon Date
ephon
SECTION 10=WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.c. 162,§25.C(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...... ❑
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,lob 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
* v
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: e
Alteration of existing bedroom es No Adding new b No
Attached Narrative❑ ova ing unfinished basement Yes
Plans Attached Roll ❑ - Sheet D
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
SECTION 7a -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
`+OWNERS AGENT OR CONT0ACTOR'A0PLIES FOR Bt1CLI ING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
,.fir/Authorized Agent
hereby'( 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 penalties of perjury.
Print N e
Signature o wner/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:
^
hampton
Street
MAY 16 100
h MA 01060
413-5 124 Fax 413-587-1272
BUILDING INSpECTIO
APPLICATION TO CONSTRU TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-SITE INFORMATION
1.1 Property Address:
M11 tNN
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZEDAGENT
2.1 Owner of Record:
Name fit) Current Mailing A dres-�L�
Telephone
2.2 Authorized Azent:
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building hg Permit Fe
2. Electricr-- (b)Estimated Total Cost of
Construction from,.(6)
3. Plumbing Building Permit Feel,
4. Mechanical(HVAC)
5. Fire Protection
This Section For Official Use Only
Building Permit Number: VNC) Datelssued: 1
z -
I LINCOLN AVE BP-2001-0931
GIs#: COMMONWEALTH OF MASSACHUSETTS
3Gs CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0931
Proiect# JS-2001-1676
Est.Cost: $8785.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Robert Thibodo 118441
Lot Size(s9.ft.): 27007.20 Owner: LAROUCHE JOSEPH E&ROSEMARIE
Zoning:URB Applicant: Robert Thibodo
AT.• 31 LINCOLN AVE
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON:51161010:00:00
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. 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 sianature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 51161010:00:00 7693 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo