17C-077 (2) i
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AF MAVIT
with a principal place of busine residence at:
AFV 7TH-y>>s
r (phone#) ,f _
do hereby certify, under the pains an enalties of perjury that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worlring on this job:
(lnsurance 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)
r.
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurmce Compauy/Policy Number) (Fxpimbon Date)
(Name of Contractor) (Insurance Com ar /Policy Number) (Expiration Date)
(attach additional shcct fnaxs ar;to ixlu6c inforznstion pcstaiuing to all oatrnctors)
m a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that wltilc hcmco A x-ra wbo employ perwas to&m i f .ac,_cucisrvrtioa or repair work on a dwelling of
not more then throe units in wh ch the hcmo ,:� r resida or oo tb c groutus zp�th=tO arc not generally coaidcrcd to be
employers under the wmk&s cempr zatim Act(GL152,m I(5)),appliation by a homoown a for a Lccnx a permd may cvidrnoc the
legal ststtrra of an amployec under the Worker's Componu i AcL
I undaiund that a copy of this r**t=c r a„y bo fbrwarted to tho Dcvwt of b,&L t id A,:6d=&OfEoa of la�—for tbn
eovaage verification and that failttre to acaue coverago undx—tiou 25A of MOL 152 can lead to tho in>posi -of criminal pcnalt ea
ooauxut of a fine of up to S 1,5oo.00 and/or imprison=,rnt of up to one year and civil peuattia in the form of a stop Work Ord--and a
fine of S I D0.00 a day tgaitx M--
For 6"to e —only
Permit Number
gof Lot si e
SECT �N 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: � Not Applicable ❑
Name of License Holder
License Number
Addr
Expiration Date
69 3
ign re Telephone
ry men''; r Not Applicable ❑
/
Company Name Regi'strati n Number
Address Ex K ation Date
Te ephone 7 5
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 affidG
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)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 _
a -
S�ECTION °DESC�RyPTIOI3F� ROPOSED WOR c ck$all a licable
W V4
xn -fi M9N�zD I '`' N ➢A3 Se 13 3 Y 3 fl 3 -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
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❑
6� Ifi New�hnuse rib or `Idditiod/to ezigt'idjtkh60'J§J'ha.Ad6MP -WAR :folRON,hk
a. Use of building : One Family V 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,a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS'AGENT"O,RCONTRACTORAPPLIES FOR,BUILDING PERMIT
f a �� as Owner of the subject proper
r
hereby authorize l f''�' /✓ �? t �� to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Own er Date
I,
/Authorized Agent
hereby decl re at the staterren s and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the nd penalties of perjur .
OQ -
:Print N
a gnatur f DQ*r/Agent
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 �
0 �n f Northampton
U ing Department
2 Main Street � ►
JUL 3 0 2001 Room 100
mpton, MA 01060 TI a ets
ne 4 3-5 ' -1240 Fax 413-587-1272 �o lzb5ft A an
I"fl rI I" J lii,Y
DEPT OF BUILDING INSPECTIONS i
NORTHAMPTON MA ninin . ..
APPLICATION TO CO CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1 SITE INFORMATION
This section"to be completetl by}zff ce
1.1 Property Address: y
3
Zone �Overlay Distrt
Elm St. District GB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: � 2L4) 0/wl
Na In Current Mailing Address: ,{` f
Sign re Telephone
SECTION 3?- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building �''1,�/ �r—"t" (a) Building Permit Fee
cJ T C
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: ...
Building Commissioner/Inspector of Buildings Date
l
BP-2002-0113
GIs#: COMMONWEALTH OF MASSACHUSETTS
=tl CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0113
Project# JS-2002-0166
Est.Cost: $3465.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq. 8.): 11717.64 Owner: WROBLEWSKI KATHLEEN MARY
Zoning.URB Applicant. Robert Thibodo
AT.• 29 HIGH ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMAO1061 ISSUED ON.•7 1301010.00:00
TO PERFORM THE FOLLOWING WORK:S I N LE ROOF
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 Sisnature:
Fee Type: Receiut No: Date Paid: Check No: Amount:
Building 7/30/010:00:00 7683 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo