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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 'may
WORla'R'S COMPENSATION INSURANCE: A ' t A.VIT
(li censerJpermi ttt:c)
with a principal place of business/residence at:
0
CJ O ow C N yA�, 0104? (phone#) <113 527�L1��S
(stirt;t/ci ty/stale/zi p)
do hereby certify, under the pains and penalties of perjury, that.
I am an employer providing the following workers compensation coverage for my
employees working on this job:
L. LQCT- 1 { Zti r0-s(laMLACc Comii.q-ny) (Policy Number) (Fx-piration Date)
O 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) (Insurancc Company/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (laatrance Compaay/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Numb r) (Expiration Date)
(atisch addRiocul shell if It,cnu y to ixuu4 nU c«sadonnornuton paL nug to )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing alt the work myself.
NOTE:ptcaac be aware chit while hccr" lxrl who employ po=—om to or repair work oa a dv%cllutg Of
not mac than thrro units in wEcb U)c LDir o Avcr rraida or co the grounds appttrtcavuii Sbrxrto arc oo(&crxraUy oomicicred to be
employers unScr tha wockr4's wia pa tticci Aa(GL152 s 1(5)),application by a homcow=for a Lccase a pcmit may cyidcooc the
]esal ruanra of an amp Ioyox under the Work o<<Compoo a& a Aa-
I undenund that a copy of this etatcrncx l may ba forwnnied to tbo DcgmeaDcat of Indautrial Aoci'.&Offioo of Inauso-for tbe
coverage verification t+nd Uiat failure to s-Varr coYcrago under soctioa 25A of Mt1L 152 can lead to tho imposition of aiminxi peaeldes
oomistiag of a fine of up to S 1,300.00 a nor kapruo=x%3I of up to one ytar and civil pcaaltia is ti,fOCm of a stop Work Order acid a
firm of St00.00 a day against mc.
Epernmit Li il er cOty
umber' Lot 4 _
Signature of Liccnsc&Pertnittcc e
SECTIONfi8 �CONST,RU;CTION SERVICES
8.1 Licensed Construction Supervisor: � Not Applicable ❑
\
Name of License Holder: `n\Ca.f� t J t `�� 0-714
^� License Number
LfO Y��0.� llF ow Z.-
Address Expiration Date
913 -, 277 ?S'
Signature Telephone
Re e"d """m"'er"mirovemerit"C n'trac"tor" A "� "
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone c.//3 SZ_7yq775
SECTION 10-WORKERS' COMPENSATION INSURANCE 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...... ❑
�61O ,E caner Exeift9f oIa
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
SECTIONS DE RIPTION OF PROPOSED'WORK (check all'applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Pr
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs ( ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: I S
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes '1 No
Attached Narrative❑ Renovating unfinished basement Yes J No
Plans Attached Roll❑- Sheet o
6 diti6r!Jo"ex isting:housing, com01eteNtlie,.following;
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?
In. 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
OWNER S'AGENT.O R,,CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 eh4e� t I las as Owner of the subject property
hereby authorize Mo—< V\ to act on
my behalf, in all matters relative to work authorized by this building permit application.
-'1 -30-03
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing applicati_QN3i are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
'1 r�0+-CV,
Print Na e--'�j�
-q- 30-03
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:
City of Northampton S`
Building Department i✓ s
212 Main Street
Room 100
�'-01\lorthampton, MA 01060
p hone 413-587-1240 Fax 413.587-1272 to
_ APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
y �xThis section tQ�be4COpl"C
1.1 Property Address: 3 � s
x
Al
X }3A K 1
Zone ' � Overlay�str
5A�r�� t A=
Dis
EIm St: trict "CH District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
M i 6�a e_I t i 222 L3,zj q P
Name(Print) Current Mailing Addre :
Telephone
Signature
2.2�Authorized Agent o
Name(Print) � 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 =0 + 2 + 3 + 4 + 5) Check Number
.This Section For Official Use Only
Building Permit;Number: Date Issued:
Signature:
Building'Commissioner/Inspector of Buildings Date
• P
222 BRIDGE ST BP-2003-0964
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 123 CITY OF NORTHAMPTON
Lot:-001
Permit: BUiidinQ
Category: BUILDING PERMIT
Permit# BP-2003-0964
Project# IS-2003-1552
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sg. ft.): 7187.40 Owner: FILAS MICHAEL
Zoning:URB Applicant: RCI ROOFING
AT. 222 BRIDGE ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON.5,16103 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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/6/03 0:00:00 3919 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo