17C-029 (3) i
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '�•. '���
WORICER'S COMPENSATION INSURANCE AFFIDAVIT
(► permittee)
with a prin 'pal place of business/residence at:
(phone#)
(strect/city/stair/rip)
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/Policy Number) (Expiration Date)
+f.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(attach additional shod ifn o=my to inchide informsitoa pertaining to alt ooatradors)
( 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 awarm that while homeowners who employ pc=m to do maintwaacr,constuctioa or repair work on a dwelling of
not more than three units is which the homoowncr resides or oa the grounds appuxtenard there arc not gcacrally coander d to be
eatploy+aa under the 'a ration Act(GL152,ss 1(5)),application by a homeowner for a Ucrase or permit may evidence the
legal o—, of an employer under the Wodcoes compomdioa Ace.
I underhand that a copy of this mtement may be forwarded to the Dcpertaro2 of Dial Accidm&offioc of lawrwoe for the
covaxge verification and that failure to secure covecngo under section 25A of MGL 152 can lead to the impoidioa of criminal penalties
OOnsiAing of a fiw of up to$1,500.00 andlor impriso=ccl of up to one year and civil pemltia in the form of a Stop Work Order and a
find o(5100.00 a day against me.
For d use onty
permit Number
�.�1� ✓ Map- Lot#
of LicenseJpermittee e
V a g3 a
CT 0 NCO STRUCTION 5ERVtCES''
.
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Nmber
Add ss Expi—ration Date
Sigr ure Telephone
e to r v`men nr"
_ Not A
PP iiable ❑
Company 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 affid,
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)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act:
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 an ssuw responsibih for complia e with the State Building Code,City of
Northampton Ordinances, State and c' Mini 'aw S,e sac setts General Laws Annotated.
f /
Homeowner Signature
.
=SECTION ' DESCRIPTIONOFPROPOSEDWOR cN ckall a ` iicable
•.:: y, ryh.'- -vkNas-Y») s> :1;,., ., k'Ni r. , „3.e'..'aX r+ .NV+�:3?c A,YEA^. , e.:, in,t »>i.,,
u
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing '
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ j Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: / r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement _Yes No
Plans Attached Roll❑ - Sheet❑
6a� IVNew WoMM,' 16rr 6dditionfto �zJstingI"'off ifik core plete the:=.followin' :
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 7�.=OWNER AUTHORIZATION -TO BE COMPLETED WHEN
O,WNERS,AGENT URiCONTR`ACTOR APPLIES-1'OR.BUILbING PERMIT
I, as Owner of the subject prop,
hereby authorize to ar
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
a
I, as Owner/Authorized Agent
hereby declare tha' the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains nd penalties of pej ry•
Pri me
Signa re of Owner/Agent Date
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 G�' 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:
ity of Northampton
1 wilding Department G`r
0 ; 2 212 Main Street S. e
s t. APR — ^00 2 i 'J Room 100 e
t_
o thampton, MA 01060
-Phone!413 587.1240 Fax 413.587-1272 �otlSlt� 3.
Q er"gip
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pr erg Address;
This section toabe completed by office
Ma Lot
Zone Overla District
y -
d _
Elm St. District CBDistrict
SECTION 2 - PROPERTY OWN ERSHI P/AUTHORIZED'AGENT
2.1 Own of Record:
Name(Print) :' Current Mailing Address:
i
-' Telephone
ign re
2.2 Authorized ent: �_..
Name( rint) Current Mailing Address:
_
Signa re Telephone
SEC ON 3 -'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building J (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
This Section For Official Use Only
Building'Permit Number: Date Issued:
Signature:
g ure:
Building Comm issioner/I nspector of Buitdings bate
r }
I BARDWELL ST BP-2002-0844
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM.-Block: 17C-029 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0844
Project# JS-2002-1403
Est.Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin James Roberts 117154
Lot Size(sa. ft.): 14374.80 Owner: POLLACK STANLEY B&
Zoning:URB Applicant: James Roberts
AT. 1 BARDWELL ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:418102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & 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 4/8/02 0:00:00 1856 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo