25C-120 (3) �.Sl1AMP�O
•�O
9 d �assxcilasctta '
r
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE AFI+II)A.VIT
0i=U-<ee/pe1m ttee)
with a principal place
/of businessJresidencej at:
`
A lI f2w 4✓��/�► / � (phone#) �ceb"3 3 9y—
(st=Ucity/stafrhip)
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 Compary/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/PoGcy Number) (F_,piration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(attach additioail lhcct if necesasry to include mforms oa pertaining to all ooairadors)
V11"am a sole proprietor and have no one worming for me_
( ) I am a home owner performing all the work myself.
NOTE:please be ague that whilo homcowacn who employ person to do naintca1nce 0¢st1=oa or repair work on a dwelling of
not more than throe units in which the homoowncr resides or oo the grounds appurtenaai thacto arc oot gcnrnity coandacd to be
employers under tho vmxirc ooa*c=4oa Act(GL152,s 1(5)),application by a homeowo r for a lia03e cc permit may-idcnoe tho
Iegzl ctaasv o£an employer under the Wodcoes Compaisation AcL
I u..,t tr. d that a copy of this ctatcmmt may be forwarded to the Depertmcat of 1r h,,trial Ace&&.&Off;oe of Imurwco for the
coverage verification and that fniltun to warn coverage under suction 25A of MGL 152 can lad to the imposition of aimirw pc uwts
comistiag of a fmc of up to S1,500.00 and/or imprho=xnt of up to oric year gad civil pemltia is the form of Stop Work Ocdc and a
fins of S 100.00 a day agninsi me
For dal use oaty
Permit Number
Lot#
Mao
Signature 4Lic=_-.eeJPc ttm Date :.
t'
EC710 GOISTR�1 T(OIV':SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�EIR e om uemen Not Applicable ❑
Company Name Registration Number
Address 1 Expir tion Date
+ Telephone
SEC71bNtO 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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes.......V No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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
EC ON �D O R PRON-6. B t c walla lic ble.E. "
� 6 ,3 i�"]•NS� M3F�s g POW'
�X
N
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
j
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: G6-e_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
s tfi N'ew ow i'd��addition to exist n h uo SI scorn' l6 he fall.wi`n
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
-SECTIONr7a-:OWNER AUTHORIZATION -'.TO BE COMPLETED WHEN
OWNERSAGENT OR3.CONTRACTOR APPLIES:FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize tr- lam , l' to act on
my behalf, in all m� ters rela 'vp, to work authorized by this building permit application.
Signature of Owner Date
as Owner uthorized A
hereby declare that the statements and information on the foregoing application are true and accurate, to my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Date
Signature of Owner Agent
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 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 C� 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:
City of Northampton
Building Department
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
SECTION 1-SITE INFORMATION
1.1 Property Address:
This section t4 b° comple ed boffiCe a .
�1'2 -
Zon x=' � Ov rtajr Dis#i►c#
„Etm&St D fr�cf C Drsi'pct
SECTION`2-- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
�d g t 9("U- /f,IL �
Name(Pr Current Mailing Address:
Signature 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) od Check Number
This Section For Official,UseOnl
B,ulIdmg„Permit-Number Date Issued:
3,
Signature x'
Building.Co"rr imissionerllnspector of`Buiidirigs Date.,
,::
BP-2002-0461
GIs#: COMMONWEALTH OF MASSACHUSETTS
� 5C 21 ' CITY OF NORTHAMPTON
Lot:-001
Permit: Buildings
Category: roofing BUILDING PERMIT
Permit# BP-2002-0461
Project JS-2002-0699
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID N U N EZ 128305
Lot Size(sg. ft.): 3267.00 Owner: HART EDWARD J&JOAN M
Zoning: URB Applicant: DAVID N U N EZ
AT 25 ELIZABETH ST
Applicant Address: Phone: Insurance:
41 BRIAR HILL RD (413) 268-3395
WILLIAMSBURGMA01096 ISSUED ON:10129101 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER EXISTING 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 Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/29/01 0:00:00 1466 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo