25C-143 (2) .y ,
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212 blain Street ' AlunApO Buddiq,
Northampton, AIRsv 01060
COMPENSATION 1INSTIE-AINCY, AFFIDAVIT
%viIh pi-m(-ipai place nQuisOsdreydence at
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do hewhy CO M, =001 the lOns luld penalkes ovinlylly,
I "in an unywyn pmvichng the WHO"Kno :11y
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(Nme of("nannsi) colvany?Anly Nzmlcj�
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Rome of Connacon ,Date)
110 011",
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hpl"aW;of an—qhv�un—u'm
tl, for the
r-nA tll t 152 Can Icid to P"':'Cl
C-nitoz ON 1h,Ocup to SIODIDO mom&jW&xmvnA of up to"M)70 W AVA;W.Ricl
SECTION t-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� R � r rt rte , = Not Applicable ❑
�,9` "Registered'Horii"e�limpr�vement�Contractor ,,� „ a�����,� �dMa.. ._.d�. ��. . � ,,_n�,���
Company Name Registration Number
�S {r'
Address Expira ion Oate
M dU 1 3 Telephone 5 7/�--
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...... ❑
�. T
'orne Qwne�i=Egemp , n°
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 fi:-which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 0.iability 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 --
SECTION 5- DESCRIPTI1:6ROF PROPOSED'WORK(check all applicable)
,.
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ^
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ ]
Brief Description of Proposed Work: _..t ic..- �% /� �- J e -,I e,,C-- I't e-;c-r u',`mss w S
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
64.-1f NeW' house` of d,6't ddition'to"lexisting-housing, complete the::follbWihk:
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 _N'0
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-'OWNE'R AUTHORIZATION -°TO BE COMPLETED WHEN
OWNERS AGENT OR!CONTRACTOR APPLIES FOR BUILDING PERMIT
l _ as Owner of the subject proper-.
hereby authorize — _._to ac or
my behalf, in all matters relative to work autho,ized by th ;ullding permit application.
Signature of Owner Date
as Owner'Aut d orized Agent;'
hereby declare that the statements and information on the foregoing applicatior are true and accurate, to be s�bfirrr ''�
knowledge and belief.
Signed under the pains and penalties of perjury.
--
Print Name
Signatur f Own r/Agen _ate
City of Northampton
wilding Department
212 Main Street lS .
Room 100 a er N/e
orth mpton, MA 01060
� aSso'
CI ` �3- -1240 Fax 413-587.1272 Plo Slte s �
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AP ATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be=completed by office,
-
c�} Map Lot Untt
Zone Ov6 1ay;District
Elm St—District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
ture Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
com leted by permit.applic ant
1. Building (a) Building Permit Fee
2. Eie.,nca! (b) i Aimated Total Cost of
Const uction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) .`� j//, Check Number
This Section For Official Use Only
Building Permit Number: _ Date Issued:
Signature: -----_ _— ----- — —
Building Commissioner/Inspector of Buildings Date
QR ST BP-2004-0233
GIS#: COMMONWEALTH OF MASSACHUSETTS
}. a CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0233
Project# JS-2004-0337
Est. Cost: $5311.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 7666.56 Owner: PIAGGI ANTHONY&
Zoning.URB Applicant: John Corbett
AT. 39 ORCHARD ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.8128103 0:00.00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS
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 8/28/03 0:00:00 1672 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo