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DEPARTMENT OF BUILDING INSPEC'T'IONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
(phone#)
(street/city/statchip)
do hereby certify, under the pains and penalties of pedury, that:
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
5�
(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 Company/Policy Number) (Expiration Date)
If If.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(attach additioml shod if nw=ary to ioc} information pertaining to alt eodtracton)
( ) I am a sole proprietor and have no one working for me.
,(<D am a home owner performing all the work myself.
NOTE:please be aware dDd while hemcowvem who employ p=oet to do maiatcna coast=oaor repair work on a dwelling of
not more than thane units in which the homeowner resides or on the grout appurtenant thereto are not gcnaallY ooasi&rcd to be
employers under the worker's c,=pcnsatioa Ad(GL152,ss 1(5)�application by a homeowner far a license a permit may evidence the
legal ctabn of an employer under the Workoea Compensation AcL
I understand that a copy of this dntement may be forwarded to tho Dcpartm of Ioduu rial Aocida&Othoe of Innavnee for the
coverage verification and that failure to scour coverage under section 25A of MOL 152 can lead to tba in�-of criminal penakies
000sistiug of a fine of up to$1,300.00 and/or imprisonmart of tip to one year and civil penalties is the form of a Stop Work Order and a
fmo of S 100.00 a day ageing mo.
For depatwe —only
�j
Permit Number
7 p, ; '/ /� G _. _ Lot#
S of Licensec/Permittce MET
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
i
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)farnilies
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
No ampton Ordinances, State and Local Zoning Laws an 4 State of Massachusetts General Laws Annotated.
Homeowner Signature
SEC I S P O (;beck l'a licabl
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ly
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ NwV-V,4zigns [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
U 0 V
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
:i
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 CONTRACTOR APPLIES'FOR BUILDING PERMIT
" cJi A Q as Owner of the subject property
hereby authorize to act on
my behalf, in all m ters rela 've to work authorized by this building permit application.
f
I C G0 e
S wner Date
as Owner/Authorized Agent
hereby dec are hat the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains(and penalties of perjury.
C_a
r� ' t , 4::�- 1 2 u « C�' C
Print Name ,
Signature of Owner/Agent Data/'
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
A"X\ \ Building Department
A 1�4
t Size
Frontage
Setbacks Fro At
e L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin
#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�z
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
This sei�tion t� com I�te ��f#
1.1 Property Address:
t
qne fwlayIIct
✓ YS2�it s.F$Fa. .VepStrlc>l',,,,,,, y 3 k. �,
SECTION 2-PROPERTY OWNERSHIPIAUTHCRIZED AGENT
2.1 Owner of Record:
a
Tw
ame(Print) Current Mailing Addr
"ANv )Ak Telephone
ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3 ESTIMATED CONSTRUCTION COST$
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) qr / 4 v __.. Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
186 BRIDGE ST BP-2001-0299
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:25C- 159 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0299
Project# JS-2001-0478
Est. Cost: $1500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 12414.60 Owner: KIROUAC MICHEL&THERESE M
Zoning:URB Applicant: KIROUAC MICHEL & THERESE M
AT. 186 BRIDGE ST
Applicant Address: Phone: Insurance:
186 BRIDGE ST
NORTHAMPTONMA01060 ISSUED ON:9119100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/19/00 0:00:00 2394 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo