12C-070 (3) .�O ` R 0
9 g (rxt� iaf &Nart Jaiilptoil
BB �asaachrcsrtta'
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AT' ' AVIT
(liccnsee/permittee)
with a principal place of business/residence at:
�o vl )ff-4, (phone#)
(stree.0 /stafr/ap)
do hereby certify, under the pains and penalties of perjury, that:
(l I am an employer providing the following worker's compensation coverage for my
employees working on this job:
�/« �_iG. 0 '(i+?I' L�1 p� ( > �': � — f /aS
ec 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 follovrlog 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) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sl me ifnocau to iachidc infocmatioc peztaiaingto ell ocasndora)
O I am a sole proprietor and have no one working for me.
O I am a home owner performing all the work myself.
NOTE:please 1x aware that white bomcown=who«aploy perzons to do UyL=tcaxa r Luc oo or repair wens m a dwelling of
not mo e than clued units in which the tw-,i 70cr raids or oa the Uvanrh appurteault therein ere ox gcnmlly comidacd to be
employes under the wtxic�s coavc=ation Act(GLI52,ss 1(5)),applic3E=by a homoov vna fox a 6ocwn cc pertnit may evidence the
legal status of an dmployer undertho Woricces Compomatiou Aa-
I uadaitsnd thst a copy of this riatcmcat may be forwarded to tho Dcpartr r of Industrial A,,6d—&Offioc of La—for the
coverage vc ifzcatioa sad that failure to acatre oovcrago under sodioa 25A of MGL 152 can lead to the imposition of criminal penalties
oomitliag of a fine of up to S 1,500.00 and/or imlxisoameat of up to one year and civil p=sltics in the focm of a Stop Work Ord--and a
fuze of 5100.00 it day tgninA toc.
For dsl use only
� permit Number
Map1# Lot#
Signahne of License c ttee pte
SECT b�l _0 I: UCTION SERVICES
. . � ..
8.1 'Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
7/k,
Signature s Telephone
ib
m r.w. e ,.. n r �_.. . ° Not Applicable ❑
Company Name Registration Number
Address Expiration Date
7
J, .4r a Telephone
s
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 affi&
will result in the denial of the issuance o the building permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(
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 mom P ION�OFlla ivak cNl+rF'lJ'H}k& A R KKF_� �3 Ea ' ah 3 si.,�F:k�?�"rw..vxi❑ Addition ❑ Replacemerit Windows Alteration(s) ❑ Roofin ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[' Other [ )
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a If N"ew h�o� se an'" f o hdditionAOTEri01_h1 EhousYrn com"ule e' he#at"lo in :
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
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"J, OWNER�AUTHO_RIZATION -TO+BE"COMPLETED WHEN
OW EI�S'AGENT,OR C4NTRACT,OR APPLIES'-FOR B111LDI1JG PERMIT
"C 1A as Owner of the subject proper
hereby authorize ✓?-4�'� /� .�40 to ac
-m/y/ h in all meters )la*ve to work authorized by t;is building permit application.
Sig re of Owper__ -- "" Date
,J as$wtdr/Authorized Agent
hereby declare that the statements and infor ation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
'p;I j 11
Print Name
Signature of Owner/Agent tDa
i
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:
orthampton e
Bu i Department .~
ain Street
AUG 1 6 2001 p
o m 100 a erlWell
am on, MA 01060 w ets�of c
DEP101 B S E
NCR1i1A. i,�A� �87-1 40 Fax 413-587-1272 p(otlSie�Plan � ��:
QtherSpectfy
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION This section to bed completed by office -
1.1 Property Address:
Map
Lot k Unit
fy�A) ti,>
Zone "Overlay Distr c .
Min- Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name int) Current i mg Address: yh�
C, i Telephone
_. )_Si tore
2.2'Authorized Ag nt:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building o>l (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
-°^ Construction from 6
3. Plumbing Building Permit fee
l u Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 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-2002-0186
GIs#: COMMONWEALTH OF MASSACHUSETTS
_ I o�aY' CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-0186
Proiect# JS-2002-0290
Est. Cost: $7400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 11630.52 Owner: PASTORE ALICIA E
Zoning: URA Applicant. B & R Siding
AT. 42 CAROLYN ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-A I Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON.•8116101 0:00:00
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 8/16/010:00:00 17806 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo