28-054 (3) a EC EE WE
MAY 15 2001
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON,MA 01060
f S,
i
d
i
e
��rtAMp�,
-
$ 6 �lxssachnsrtfa'
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A1F'FTDAVIT
c
Oicenstdpermittee)
with a principal place of business/residence at:
Y Q (phone#)
(s11-eet/city/state/ap)
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:
(Insurance Company) (Policy Number) (Expiration Date)
O 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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lasiaance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(attach additional shoot ifn«rssiry to include information pertaining to aII ooviraewrs)
,'14'�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 aware that while homeowners who employ pc=m to do maiatc=tce,emstvajon or repair work on a dwelling of
not more than throe units is which the homeowner resides or on the grounds apradenaa thereto are not geoer&4 oomtdcrod to be
employera under the work, oration Act(GL152�s 1(5)),application by a homeowner fora Gccase or permmit may evidence tho
legal d-1- of an employer under the Workeet Compensation Ad
-
I understand thud a copy of this mtcmmi may be focyA ded to tbo Deputam2 of Industrial Acciden&Offioe of Insiuwnoe for the
ooverxge verifiattioa sad that failure to aeatre Coverage under section 25A of MOL 152 can Icad to the imposition of criminal penalties
ooaabling of a She of up to S 1,500.00 and/or k4 isoemncrt of up to one year and civil penalties in the form of a Stop Worst Order and a
Em of S 100.00 a day against tnc
For deputnrmtsl use only
Permit Number
-S /O
a'/ Mao
#
tcenseelPermittce
ECTION'8-CONSTRUCTION ZERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
�J
Company Name Registration /Number
t� & if V;kdG I C
Address Expi do Date
Telephone
SECTIQ(V 1.Ow 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.
ned Affidavit Attached Yes....... ❑ No...... ❑
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 hon►c 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
E-SCRIPTION OF P89EMERN. Offticheck
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding/[ Other [ ]
Brief Description of Proposed Work: rf-*QLI) r -_crUWg, WJ P-'" -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
mum
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?
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 R ICON" RA BE COMPk4TED, WHEN
PLIiv R UILRiT OWNERS NN 611 CTOR R EM
l as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Ow uthorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, y
knowledge and belief.
igned under the pains and penalties of perjury.
�, ►� ' r i
Print Na
Date
ure of Owne Agent
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:
City mpton
rtment
21 M i reet
pKtl1tiA _ m 1 0 01060
NOR
IM 13-587.1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC 11,0#1-SITE INFORMATION
1.1 Property Address:
o
(le r�
q
J/b i
SECTION 2-:PROP„E 2TY"QWNERSHIP7AU'THORI,YEO AGENT
2.1 Owner of Record:
ame(p t) Current Mailing Address:
`sue'if agz S'G
Telephone
Signature
2.2 Authorized Agent:
�D►Yley � r-S�-+� ���O/'�Ztou� .sf G-�_,s.�ra /j1�
Current Mailing Address: d'/O
Name(Print) g
gn—at ure Telephone
CTIf�N'3 Es?IMaTE0 CCENSTkUCT1ONCOSTS
Item Estimated Cost(Dollars)to be Official Use'Ohty
completed by ermit applicant
1. Building (a) Building Permit"Fee
r
2. Electrical (b) Estimated Total Cost of
Construction from,,(6
3. Plumbing Buildm �Permi Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4 + 5) Check Number
This Section:For Official Use Only
wilding Perm it Number: gate Issued:
Sigrtiatu�� .
Bwlc ing,Cor mir tsioner/Inspotdr o.f jui ings Date
r, BP-2001-0930
GIs#:f COMMONWEALTH OF MASSACHUSETTS
Ay CITY OF NORTHAMPTON
Lot: -001
Permit: Buildings
Categ_ory: vinyl siding BUILDING PERMIT
Permit# BP-2001-0930
Project# JS-2001-1675
Est.Cost: $5300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sa.ft.): 1 2066.1 2 Owner: KMETZ JEFFREY&LISA LEFEBVRE
Zoning: SR Applicant. John Corbett
AT. 616 RYAN RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.51161010:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 5/16/010:00:00 1061 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo