25C-143 (3) b,12 i2 U:; 11;45 14125 2915 4 1 B M S FADE:
i%.,C.t ROOFING
40 MAtW AVE..
P.O. BOX 309 FES EA THAf�1fa'`1 ON, MA 0102.7-0309 TE)N
PHONE (413)527- 4776
FAX (413)527 4;469 ImpWim
Date, MARCH 24, 2003
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMTENSA`zION INSURANCE AFFIDAVIT
I, �r
(li censer./pelmi ttec)
with a principal place of business/resideuce at:
q Mjp` oci- ow z 6n 01OL7 (phone#) 9(3-52)-477S
(6tr=Uci ty/statelap)
do hereby certify, under the pacts and penalties of perjury, that:
am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurancc Company) (Policy Number) J (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 Conipany/Policy Number) (Expiration Date)
(Name of Coutracto.) (Insurance CompauyiPolicy Number) (Expiration Date)
(Nance of Contractor) (Insw-anct: Company/Poky Nmnber) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Numtr_r) (Expiration Date)
(atradi additicnil sb'-c if noccsiary to induce iafornutioa pertaining to all cbatradors)
( ) I am a sole proprietor and have no one workdng for nie.
( ) I am a home owner performing all the work myself.
NOTE,.plea=tx ague that winle wbo crmploy pazons to des tnmintraance,corz"n::uoa or repair work m s dwelling of
not mcct tb:n Lbroa units in wEidi the ho-.ik�. tivcr raids et oo t6e aoucx:s appurteauri thacto'uc"ot L'axrally coasidcred to be
employer=under the wozic&s cctr+,=, aticn Act(GL152,s31(5)),application by a homeowner for a Uocnsc a permit may-id—the
Icgal d2.tX a of an employes under tho Wixkxes Cooapemaiion AtL
I underiUnd thst a copy of this cute.,c t ruAy be forwarded to tbo DeSxutuxnt of Industrial Accid.-,dY Oflioo of lmuraoee for tbe
coverage vaificatioa and nut failure to ao uc owmmso under scdioa 25A of MOL 152 can Icad to tho imposition of criminal pcmliia
00austing of a fine of ug to S 1,500.00 aruyor i np isoamcnt of up to ore year and civil peaaltio in dr form of a stop Work otda and a
fine of S100.00 a day Igaiast Ur–
p-6gPu zxresl u,o«zty
Permit Nwntex
—
4; Signature of Liccns-cepermittce LbLe
SECTJ'OV 8x CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not- 7
Applicable ❑
Name of License Holder: ��� �'S\�—' 0 !7 —33
License Number
�
o-o t. V aA Y " a• 0 1 0 2 7 tilt
Address` �''''� ��' Expiration Date
Signature Telephone
C9Re`"g"s'te" "eQmimarovement'Contractor� ' *t+ * , "r�r`" ` " ""�} N Not Applicable ❑
iz- 4 23s
Company Name Registration Number
Address Expiration Date
1
90 1�cz: YLti QV `L � r. Vl-La. Telephone q(3 _57_C/77S
SECTION 10-WdRKERS' 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...... ❑
. ''ome �vnerExempt1i 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 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
N.
SECTION 5 DESCRIPTION OF PROPOSED WORKkcheck all*applicable
New House 13 Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:At-yLe,i(� cF
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
5a1f�New�h�o'fi�se�''and�or-�"addition'to'existing dousing com'pleteF the followfn`g;
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
I. 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,CONTRACTOR APPLIES FOR BUILDING PERMIT
CJ 7- as Owner of the subject property
hereby authorize m0.f"V-\ :�)i-V, R L= Kc, to act on
my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner Date Z , _ ��
as Owner/Authorized Agent
hereby declare that the statements a d information on the foregoing app ation are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
V'V�0.rk 3:�)0:; 5\
Print Na e�
Signature of Owner/Agent Date
s
1
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:
t
City of Northampton S o r>
Building Department
212 Main Street e
Room 100
Northampton, MA 01060 et
phone 413.587.1240 Fax 413.587-1272 to
o
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A,ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: � yThis sec ion�to`be4complete�
r' Mar .; � .
Zone �: �O er.lay�Distr c
Elm St:District ��,CB,,Distnct t3 t.
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C c-
Name(Print) Current Mailing Address:
<413 -,-519 135?
Telephone
elephone
2.2 Authorized Agent:
"\,, C`� ����� C) �oX ::sb`1 �t Y1 . 0to2�
Name(Print) � Current Mailing Address:
7
Signature Telephone
SECTION3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
AA
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) Check Number
This Section For Official Use Only
Building Permit,,Number: Date Issued:
Signature: ;
Building Commissioner/Inspector of Buildings Date
BP-2003-0895
GIs#: COMMONWEALTH OF MASSACHUSETTS
116100,14 .; � CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0895
Project# JS-2003-1440
Est. Cost: $11000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin RCI ROOFING 126235
Lot Size(sa. ft.): 7666.56 Owner: SALZMAN JULIE
Zoning URB Applicant: RCI ROOFING
AT: 41 ORCHARD ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTON MAO 1027-0309 ISSUED ON:4123103 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:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/23/03 0:00:00 3882 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo