25C-197 (2) i
11 1
r
t )
x
}
f
i
} I
r
-
r
! e
t/�u _
z }
y
i
: 4-�1tAMpTO
4 B _ j�lasaACf[ttsrtta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ,
WORKER'S COMPENSA'nON INSURANCE AFFMAVIT
with a principal place of business/residence at:
��r�4=v��,C%�=L ��', l v?`; V '�4�(phone#) y��'<} 'C%C
(•-�sy-„t/cih',''statl-�aP) C� !cam�j �� � _ ��i�t=t � C
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:
(lnct=aa Company) (Poky Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed(elow w wing worker's compensation policies:
(Name of Contractor) (Znsurancc Cornpauy/Pclicy Numbcr) (Expiration Date)
(Name of Contractor) (Laurance Compmy/Policy Number) (Expiration Date)
(Name of Contractor) (Ins=cz Company/Policy Number) (Expiation Date)
(N e of Contractor) (Insurance Company/Policy Number) (Expiation Date)
(attach 'oaal r15cci if nocczsiry to mchlde infonaut con pertaining to all ccatmaori)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awart that while homcowncca who ploy perzons to do 0j3_i0+z*•j„r cva ucxion or repair wocic oo n dwelling of
not meet than throo units in which the homooavcr r=dcs or on the wounds appurtc�then t arc Dot Ccncrtty wasidacd to be
nPloyrrs under the work 'o=Tc zsation Ad(GL152,ss 1(5)),application by a hotncowoa for a lieeax a permit may evidcnoe the
legal ctnhrs of an amployor under tho Workcex Comp.Ation Act_
I understand that a copy of thin rtatcmcni may be fotwnrded to tho DcperimcaQ of Indi-ibial Accidca&Offioo of Imrusnoo for the
coverage verification and that allure to scatre coverago under scetioa 25A of MOL 152 can lead to tho imposition of crimin Penalt:ea
oonsisting of a fine of up to S1,3OO.00 and/or imprisotxma of up to one year and civil peualtics is the form or a Stop Work Otdtr and a
find of S1OO.QO tgainst t
1 4Forr deps:Nuwmber tsl tuo Doty
pt.nntMap4 lot 4
f Liccnscc/p't.tt'e LbLe
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Apppplliicaa�ble ❑
Name of License Holder : ±_��� r /T i � 14L,1 �' �3
r License Number ,
Address Expiration Da e
Signatu Telephone
WHOM L a :.: , ,, Not able ❑
r vemen n r r. ," 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...... ❑
�11� ,aHome��� caner EXeniptuon
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
t ,
SECTION 5 3'QESCR IPTION_:O "P.ROROSED YVORW cli'eck all.a" `li"cable
3, ,�hzgvilm*.,µis,..eN u S rvap;4Sd.3?c;F 9'p .3
af ., ; r
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: rc�n�' t L I ' acy���t' — i2 t rp O UL
g g bedroom Ye
Alteration of existing bedroom Yes No Adding new bedroom Yes [-s'" No f
Attached Narrative 0 Renovating unfinished basement Yes _I,, No
Plans Attached Roll o - Sheet 0
GCENew�to sea�d�oraii8ition.to-ezistng�lioius�ngcomete fhe fol'lowinn
a. Use of building : One Family --C� 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
OVYNEOSS;, GENT`OR'CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authori e _ I to act on
my behalf, in II 't e ative to work authorized by this 6uilding permit application).
( r, c�
Signature )Cnf r Date
as Owne({``%Authorized Agent
hereby declare that the statements an information on the foregoing application are true and accurate, t& AZ-best"ef,my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print NamV'4'�—e
Signa Agent Date
f r
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 Sp ial 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 wa7er or wetlands? NO y r 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
.a/
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:
tatU9
��_ � ; Glty of Northampton N' a
!
Building Department Ourb�Cctt
}
�
s , .-21,12 Main Street Sewer�SeP,Ila°
i �.rl ^ ,;, I. �' ° Wa erJWell
q, z Room 100
r
I North 'mpton, MA 01060 Two Sets ofi S ruct
. � �
I phci"rte 4`13 58 1240 Fax 413 587 1272 Plot/Site Plans�� y � 3
s
i C K aro e
Other�Speclfy �do
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEA CT10N 1 - SITE INFORMATION
�— — This section to be completed by office
1, 1.1 Property Address:
n �, � j/ Map Lot Unit
'J Zone Overlay District
1 V Elm St. District'_ CB District
I SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ,
-Vl 57
Name(Print) 4L Current�Mailing Address
_ elephone
— ----- -
Signature
2.2 Authorized Agent:
`. �'�.� f V U6C-f0
Name ri t Current Mailing Address:
S' Telephone _
CTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
COMID leted b ermit a licant
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) j f7 d Check Number SU
This Section For Official Use Only
Building Permit Number: Date Issued:-
Signature:
Building Commissioner/I spector of Buildings Da 6e
T. BP-2002-0932
CIS#: COMMONWEALTH OF MASSACHUSETTS
191 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2002-0932
Project# JS-2002-1509
Est.Cost: $5500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R JOSEPH MURPHY 059333
Lot Size(s4.ft.): 6403.32 Owner: CREELY ANN&BRIGITTE PAROT
Zoning:URC Applicant: R JOSEPH MURPHY
AT. 65 NORTH ST
Applicant Address: Phone: Insurance:
65 RESERVOIR RD (413)584-1515
LEEDSMA01053 ISSUED ON:4125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL LIVING RM, REM NON BEARING
WALLS
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/25/02 0:00:00 579 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
t,4^'�l
IN
x
f
65 NORTH ST BP-2002-0932
GlS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 197 CITY OF NORTHAMPTON
Lot:-001
Permit Building
Categ=: BUILDING PERMIT
Permit# BP-2002-092
Project# JS-2002.1509
Est.Cost:$5500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., Licenser
Use Group: R JOSEPH MURPHY 059333
Lot size(sa ft.): 6403.32 'Owner- CREELY ANN&BRIGITTE PAROT
ti
7�-194e:URc Anpliiant: R JOSEPH MURPHY
65 NORM'
Apolicant Address: Phone: Lksgranggi
65 RESERVOIR RD (4131584-.1515
LEEDSMA01053 ISSSM ON:4125102 O:U .tIQ
TO PERFO M THE FOLLOWING WORK.-REMODEL LIVING RM, REM/NON BEARING
WALLS
POST THI§CM VISIBLE ERQM In STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter.
Footings:
Rough: Rough: :q 10� House# Foundation:
f ` lj't!` Driveway Final:
Final: Final: (l o2 00
Rough Frame:
}
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: _ _ -insulation:
o 5 1p-po2,�
Final: Smoke: Final: 11K 6
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPWNW11ATI N OF
ANY OF ITS RULES AND REGULATIONS.`
,
Building 40101 0.00;41ft 579
212 Main Sbve%Phone(413)587-1240,Fait:(413)557-1272
Building Comm�sioner-Anthony Patillo
a