17C-054 (3) �t►tAMp20
8 6 �lasaaehtesrtta'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMI AVIT
(li censee/permi ttee)
with a principal place of business/residence at:
,?IZZV hone#
"d' ( city/statrJap)
do hereby certify, r 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 Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional ahcet ifneccsstry to include infbrMA ioa pertaining to ell ooctactors)
m aole proprietor and have no one"working for me.
( ) I am a home owner performing all the work myself.
NOTE:prose be awatn that while hooxowvcra who employ pasoas to do R- +,, c cc or tcpair work ao a dwclliag of
not More than three units is which the homoowncr midcs or oa the gnuoris apµuteaaat thereto arc not gcnorally ooaridatd to be
ca PloYas unites the-mkeel,compass4cn Act(GL152,ss 1(5)),application by a homeowner for a lio=a cc permit may evidm-the
logal status of as omployor under the Wodcoet Coropomatioa Act
I uod—tared d-4 a copy of Chit ctatemeat may be forwarded to the Dcpartmcot of lodLtstrial A ocidmts'OfSoo of In--for the
covet"vaificatioa and that failure to secure coven go trader zocUon 25A of MOL 152 can lead to the impositioa of aiminsl pcualtics
ooasking of a f ere of up to S1,300.00 and/or imprisoamatt of uP to one year and civil pcnaltia in the focm of a Stop Welk Order and a
film of:S 100.00 a day ag&in5t me.
For dgwtam uto only
Permit Number
Maps Lot#
• Si of Li ermittce 7 Cate
/
SECTS t:bNSITRUCTION SERVICES
8.1 Licensed Construction Supervisor_ / Not Applicable ❑
Name of License Holder : %1•�-l�L�`. T 3/`'/f>� C
License Number
Address ^ /" /// Expiration Date
Signature /; r Telephone `s
Y k PP
Not Applicable ❑
Company Name Registration Number
Address -, ,/ ` Expiration Date
1
Telephone ,� _ C 5 .
SECTION 10 RKERS',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.
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
c I]aa licaiPRPSEVR O Omit c le
9a ra a
9 MOO
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofin
Or Doors ❑
i
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding n? bedroom Yes No .• E'
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet 0
�� If�Ne hu'us a��i'ii�oradctitionto'�existintioising -cornp"letethe�follow�n'>r:
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 Ne
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=OWNERAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT_;OR;CONTRACTOR;APPLIES'FOR,BUILDING PERMIT
Vy� a AJ S £ A/ s as Owner of the subject property
hereby authorize � A 6. d to act on
my behalf, in all matters relative to work authorized by this building permit application.
1�- ,•ate'
Signature of Owner I Date —
,ae-6Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under t ins and penalties of/ rjuryry.
Print Name
/r 1 /r
Signature -eVI%C/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 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 of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587.1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVAT D S E OR T F EMILY DWELLING
SECTION 1 -SITE INFORMATION - SPEC\aKS
GIN �,: ..
'Y mpl"eted,by'office
1.1 Property Address: tip Y
/J� Ma'P 'of
, r
� E
EI„m,StaDistrict:
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-
r
wf r
Name(Print)h V Current Mailing Address:
P
Tele hone
Signature
2.2 Authorized Agent*
H
Name(Prir�ty 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 � (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 Onl
Bulldln PermltNumber rs6''2 ?Z -psi Datelssued:"" �
AW
Slgnatur`e, BuildmgCoinmissroner/Inspectorof ,
Buildings. ... Date....
BP-2002-0504
CIS#: COMMONWEALTH OF MASSACHUSETTS
, 1c: t7c psi CITY OF NORTHAMPTON
Lot: -001
Permit: B u i I d i ng
Category: BUILDING PERMIT
Permit# BP-2002-0504
Proiect# JS-2002-0761
Est. Cost: $2935.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo
Lot Size(sq. ft.): 19645.56 Owner: MUYSKENS JOHN JR&DEBORAH C
Zoning: URA Applicant: Robert Thibodo
AT: 156 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTON MAO 1061 ISSUED ON:11191010:00:00
TOPERFORM THE FOLLOWING WORK.STRIP TWO LAYERS OFF OF EXISTING AND
RE-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 11/9/010:00:00 7992 $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo