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DI',PARTMENT OF BUILDD? G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COM-PENSATION INSURANCE AFFIDAM
(li a;rrscrJpern�i tte�)
with a prig Ipal place of bus'Messlresidenc-- at:do hereby certify, under the pains and pen,lties of perjury, chat.
( ) I am an employer providing the follu'vim" .vorkers compensation coverage for my
employees working on till's job:
(Ias=ucl� Company) -- (Polio,;Number) - --- (Ex-pimtion Date)
O I am a sole proprietor, general_ coimactor or homeowner (circle one) and have hired
the contractors listed below who have the worker s compensation policies_
(Nerve of Contractor) (Insurar.c° Compa,-,-,,'Policy N=b--r) (Expiration Date)
(Name of Contractor) (Insurance ('0I11D2IIvIP0!lc�I Number) (Expiration Date)
(Name of Contractor) (Ins�r �c� C,�mpany foGcy Ntu7�1x_r) (Expiration Date)
-------- ----- --
(Name of Contractor) (Ins�rdnc� Comte��y/Policy 1 tumtr r) (Expiration Date)
(attach addit mil r?cot fntceissry to inei is cx,ni:ix :acaing t�ell axe ndc:.)
i
n a sole proprietor and have Iry one -vhrkho for me.
O I ain a home owner performing all t_le , or:: nwsclf.
NOTE:p[c-.sc be Awarc that whilc C,:ntr.:C�:cct or lzpurr\,ork on a d«clling cf
not a ccc tl n lhrco units n tc�dt he lW cauvcr rest s cr a:Lu w Fu tc: rl llxzc o t c xt(;nc lly oomid_rcd to be
eatployc;a ua�.er the tvorka'i ce pczatim Act(GL152yi[(5)),-S is nice by a h(mn.ot nor for a licaisr.cc permit t^.Ly e-,4,dcnce tt:c
legal statue of e-n e mployor under the,Workor'a Comp tion Ad_
I undcntand flat a Dopy of tlum ctntcmcut a y bo forw i,3 to d1 DcSxirL—d of Ir serial Aocidcntf Offi—of[rru—CO for 11m
coverage vcrificatioo and that failure to_xztrc—c-ago ur -r sc.;'.iou 25A of MGI,152 can Icad to the invosiiion of a-mi peril -
coaitlting of a runt of up to S 1500.00 anNor imprison tx of up to`}gar". i civil perult cs in dx fc 'of a Stcp Walk Olds.'and s
fiat cc:s 100.00 a day ig�un:t ax,-
- Foe deputrmtal uie Drily
J h�-tp;J I,ot r
�-ttnrc of LicrrnscrJPcrmittcc �
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
=---- - -
License Number
Address Expiration ate
i nature Telephone '
9Registerectl Home Irripr`ove'ine'iit Co"ritractor ,,, `w ,g ,, „ ;, Not Apph able El
Cornany 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: =..Homeowner Exemption
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-vear 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 buildiny-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 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachuseo.s General Lams Annotated, you may be liable for person(s i
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 Lwws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing /
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a."1 NeW,,-Kd se.and�or`addition o existing housing, complete the.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?
I. 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 Private well City water Supply_
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of t:,e subject property
hereby authorize to act ors
my behalf, in all mat s rela vVo work authorized by it - .,u ldin permit application.
Signature of Owner Da.e ------
I, as Owner/Aut!,on zed Arehereby e are�Ih�the statements and information on the foregoing app ication are true and accurate, to the best of my
knowled and ef.
Signed under the pains and pen ies of perjury.
Print ame r
nature of Owner/Agent Date
s
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 r✓etlands? 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 1
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 Sta't ""fper
Building Department
212 Main Street SewerlSe� rc: ataf3 °,
Room 100 WaterlWell ua
Northampton, MA 01060 Two Sets�of fr c u a1 , an"s NIL—
phone 413-587-1240 Fax 413-587-1272 PlotlSi e Plans
Other' eclfy
APPLICATION 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
f" Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pant) /� .,,.gent Address:
a — -- ----------—---------- ----- —
Signature —T
2.2 Authorized Agent:
m in ,�_� C . rent Mai intt Andress ^ /°7
Signa re Telephone
-- -- --- ----
SECTION 3 - ESTIMATED CONSTRUCTION-COSTS
�t=m stima� Fd "Dollar,,
Official Jse Only
Cry,, ted �r�li i ap 11Ca -----
---- ------- -- �1
1 Building ,. f (a) Building Permit Fee
` c C-l'— --- - - ---- ---
2 FIP ..rical 1 ,b; i timated Total Cost of
-- ----------_---._ ___ _i ; C(�ristruction from (6) j-
3 Plumbing Building Permit Fee
4- Mechanical (H VAC)
5. Fire Protection
ev - --._
6. Total - (1 + 2 r 3 + 4 + 5) LC,heck Number 73
This Section For Official Use Only
�' _ Date Issued:
Building Permit Number: -_-- -�-- — --_----------_--__-_.____
I Signature:
Building Commissioner/Inspector of Buildings Date
BP-2003-0634
GIs#: COMMONWEALTH OF MASSACHUSETTS
`.. X51✓-2b CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-0634
Project# JS-2003-1043
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERTS ROOFING
Lot Size(sq. ft.): 6098.40 Owner: SHAUGHNESSY HANNAH&MICHAEL
Zoning:URB Applicant: ROBERTS ROOFING
AT. 153 BRIDGE ST
Applicant Address: Phone: Insurance:
30 Edwards Avenue
WESTHAMPTONMA01027 ISSUED ON:1117103 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP AND 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/17/03 0:00:00 1739 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo