17A-303 (4) �TttA 4P�0
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street e Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE f,.IFIDAVIT
(Ii aense�/permi ttee}
with a principal place of business/residence at:
l ql. (phone#) S2 7--006
(street city/stair/ap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employ°r providing the following worker's compensation coverage for my
employees worlang on this job:
(Insurances Company) (Policy Number) (Expiration Dale)
( 1 I am a sole pro;netor, general conn-arcn-or or l omen,�zrr er(cirr'e on0 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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atfach additioml sheet if n,xs to include informarion pertaining to all ooatradosa)
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 awarrr d ai while homeowners who employ pc==to do mamtcnance,consftucUoaor repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto arc not generally coosiderrd to be
employers under the worker's compensation Act(GL152,a1(5)),application by a homeowner for a license or permit may evidence the
legal stairs of an employer under the Worker's Compensation Act.
I underst=d that a copy of this altemeat may be foewarded to the Departmccd of Indu trial Aomdea&offioe of lnvAnum for the
coverage verification and that failure to secure cove-go under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or imprison of up to one ytar and civil pcnzltia in the fain of a Stop Work Order and a
fine of 5104.00 a day against ma
For dgMt=W use only
Permit Number
Map# Lot#
Signature of Li ermittce Mte
^
/, ~
`
oVk�ECTION�8-CD�NSTRU�CTION�SERVI�CES
I Licensed Construction Supervisor: Not Applicable 0
Name of License Holder 014,W5[-r1 PftP 06 30 6
License Number
Address Expiration Date
Signature Telephone
Not Applicable 0
Sal "'11 200
Company ame Registration Number
(3r,1665 ST 02,7
Address 7 Expirafion Date
ev�l �;�, ;>& I
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 issuancq of the building permit.
It
The current exemption for^hoozmnmnem^was extended toinclude one(1) or wro(2)bunUiem
and to allow such homeowner toeugugeuuindkiduu for hire who does not possess ulicense, provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own o parcel ofland on whichbe/she resides m intends m reside, onwhich 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 shpIl 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 buildinp_permit.
As acting Construction Supervisor your presence ou the job site will he required from time to time, during and upon
000zp|ebonofdbe work for which this permit iuissued.
Also he advised that with reference to Chapter i52(VVodem` Compensation) and Chapter l53 (LiuhUityofEoployemto
Employees for injuries uotmaubingbnDeud)oytheMuaouchuueumGeuon|Lm*oAouoated.you may be liable b/rpcmou(m)
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, and Local Zoning L vs and S fM b General Laws Annotated.
Homeowner Signature
r +
_CT I01 5 DESCRIPTION OF PRO�'OSED'WORK(check' I1 a�ulicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 7W OFF � 9-r— y /Z p-p�f � SrCyL/G/t
u,./7� iVywL%rvE
�Gr P r w pL�6L'oc'0
Alteration of existing bedroom Yes No A ding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
A A0 E L �f as Owner of the subject property
hereby authorize to act on
my behalf, i I matters relative ork authorized by this building permit application. f
Signatu wner Date
607��C' V_ as-6owWr/Authorized Agent
hereby declare t at the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
oo6signecl under the pains and penalties of perjury.
10 1 W � PAY10
Print Name
0(3
Signature o Agent Da
, 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 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:
, r •
Y.�
City of NorthamptonA. Z
Building Department
212 Main Streetz�
APR 13 Room 100
Northampton, MA 01062
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
1.1 Property Address: This section to be completed by office
1 0 2 f f(L'u'-Q es Map — Lot—,31)3, Unit
Zone_ O"rlay,District
Elie St C?Is#rift GB Dlstr)ict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ow-per of Record:
to
Name(Pri Current Mailing Address:
t� �?C -C Telephone
Signature
2.2 Authorized Agent: (0 iv
fMtiSA-E PAD QE 51(1PWV k00F(--L-6 122 '4r'/&6s SJ 7?i^—IP-I?Ixl
Name(Print) Current Mailing Address:
Signs re I Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 1`d O j d (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) Check Number 4-4- 0 "
This Section For Official Use Only
Building Permit Number:. 17 Date Issued:
Signature: f
Building Commissioner/Inspector;of Buildings Date
File#BP-2000-0885
APPLICANT/CONTACT PERSON DE Sheppard Roofing
ADDRESS/PHONE 17 1/2 Briggs (413)529-0170
PROPERTY LOCATION 107 HILLCREST DR
MAP 17A PARCEL 303 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /
Tvneof Construction: STRIP&SHINGLE ROOF&REPLACE SKYLIGHT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 066306
3 sets of Plans/Plot Plan
THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
AOW
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation C ission Permit from CB: hite tore Comittee
�$ Loam m
Signature of Building icial lYa te
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
107 HILLCREST DR BP-2000-0885
GIs#: COMMONWEALTH OF MASSACHUSETTS
-Map:Block: 17A-303 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate,go1y:roofin g BUILDING PERMIT
Permit# BP-2000-0885
Project# JS-2000-1645
Est.Cost: $5693.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 066306
Lot Size(sq.ft.): 21 823.56 Owner: DONNELLY TERRENCE P&GAIL K
Zoning.URA Applicant: DE Sheppard Roofing
AT: 107 HILLCREST DR
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413)529-0170
EASTHAMPTONMA01027 ISSUED ON:4118100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF & REPLACE
SKYLIGHT
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 4/18/00 0:00:00 1926 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo