17C-006 (3) r
l r \T \
4'Ct1AMP�, oa'+�o�
O O
a � �a1f a[l�ttfrltf
of 'Wart4anlvton ID
m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION WSURA.NCE AFFIDAVIT
(li=seefpermiU=)
with a principal place of business/residence at:
J dad ,ys , (phone#) '
(6trect/city/stA62ip)
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)
( ) 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/1'olicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/I?olicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poficy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atttch tdditicml:fled iftteaasry to include irdocntafioa rte__=^�to nu��ndon�
( I am a sole proprietor and have no one working for me.
P P $
( ) I am a home owner performing all the work myself.
NOTE:please be aware;that while homeowners who employ pc==to do m aini.,,aace,corffiry on or repair worts on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant tb=w are not generally ooasidcred to be
employers under the twrkees compensation Ad(GL152,w 1(5)),appdcafien by a homeowner for a liaise or permit may evidence the
lest!rl-tus of an employer under the Workoet Compensation Ad.
I understand that a copy of this datement may be forwarded to the Depwtmcof of Lsdustrial Aocidw&Offioe of&rsurs+ooa for the
covexagc vai&ation and that failure to scatre coverages under section 25A of MGL 152 can lad to tba imposition of criminal penalties
oomisdng of a fine of up to 51,500.00 andlor kqxbo=3cnt of up to one year and civil penattia in the form of at Stop World order and s 1
frmo of S100.00 a day against Me.
Foe dgaatwwW use only
PcrmiYNtlmber .
�'✓`� '✓ �
, ,/2 Z�' Lot#
Si
of Li ttce
..
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: I A f _>
License Number
Addre / ,�/ Expiration Date'
Sign ` Telephone
//�• /y, Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone �- 4 .
SECTI]N 10�' NORKERS'COMRENS�►T10N iNS11RAGLFIDA1fIT
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...... ❑
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
-1 ,
14111 I�
r
n
e
WON
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:- T"1 'r t'" . » �' F ".° Q:st t"
Alteration of existing bedroom Yes 1/" No 'Renovating new bedroom Yes � No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll o. Sheet o
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 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
10a"NOW-MN'T
Jereb)�autas Owner of the subject property
hori _ ` ° to act on
e If, in all matters r Iative,to wo uthorized by this building permit application.
Signature o Date
" f con's >$'. , as Owner/Authorized Agent
hereby dec are that the statements and information on the foregoing application are true and accurate,to the best of my
knowledge and belief.
Signed under the pains and penalties of erjury.
Print Name
Signature ner/A 0i Date
M1 5id.a k Y h y q�7
1
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 v f
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.
FF
4
'NOV City of Northampton
.�
_.Btailding Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
E7 1' 51T� AST ia
1.1 Property Address:
T
E G,
CT ON 2 P120pEf2TY OYVNER H(P/Ayi-S �R�ZED AGENT
2. wner of Record:
an (PI'nt) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
S �,. w ter.
Name(Pr' t) I Current Mailing Address: IV
Signat Telephone
Qg
a, ' @t v
�'d§.,;,",✓r_ i;S ,W,>» x �33NN3'r.,-., ;!`F „�yW,%'-. s, ,,, 3,, fV,A P.
Item Estimated Cost(Dollars)to be OfftGial Utl(
completed by ermit applicant 1�0,111111111111
a1111(�Ii aL'fit�I�
1. Building � � � , �J
3il?1,r,.' iii at. xa�, �
ll
2. Electrical bsttiTot �_
It
3. Plumbing �iildmgermltFee 3 � �
E j A •£' '
4. Mechanical (HVAC)
5. Fire Protection
6 Total (1 + 2 +3 +4+ 5)
r Nctrxtb �,
3
ME ro '. ;Y,� '�" r
�� yd0
a b 3I I
�
ix a3 , � I �3ir 3 av 3
�d n7 r
1 sT BP-2002-0495
CIS#: COMMONWEALTH OF MASSACHUSETTS
V&VJ
alo
ck: 17C 0o6, ;I* CITY OF NORTHAMPTON
Lot:-001
Permit: BuiIdina
Category: roofing BUILDING PERMIT
Permit# BP-2002-0495
Project# JS-1999.0554
Est.Cost:
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C & T Construction 062884
Lot Size(sq. ft.): 9539.64 Owner: FLEISHER ARLENE
Zoning: URB Applicant: C & T Construction
AT: 24 LAKE ST
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON.•
TO PERFORM THE FOLLOWING WORK.S T R I P TWO LAYERS OFF OF FRONT PORCHES,
PLYWOOD ANSD RE-SHINGLE
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 11/9/010:00:00 2892 $50.00
212 Main Street,Phone(413) 587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo