17C-072 (2) 1 4�1PT0
B 6 �+tsaschnactta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMTENSATION INSURANCE AFFIDAVIT
(licenserlpermittee)
with a principal place of business/residence at:
(phone#)
(&t=Ucity/stafdzip)
do hereby certify, under the pains and penalties of perjury, that:
O 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)
r.
(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)
(attac3t additiocal shoct if n6ocuuy to inctude infocmirioa pertaining to ell oodrettors)
( 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 aware that whiio homcownm who employ persou:to do mamim,ncc con3truction ar repair wvrk ou a dwelling of
not mote than LL-00 units in Which the hotnoov v resides of on tho grounds appurtenant iberdo arc cot gcocrany ooaridcrcd to be
employes under the works caxrva>:4oa Act(GL152,ss 1(5)),application by a homeowner for a Ucrase or pcfn may evidence the
legal stxtua of as employer under the WO&Ces Compomation Ad_
I understand thsi a copy of this rtatcmcui may be forwarded to tho Depertasco2 of Industrial Ac6dm&Offioo of In usnoa for the
covauge vc ificatioa and that failure to so=coverago under soctioa 25A of MGL 152 can lead to the impositioa of-mmll pcnakics
oomisti of a fine of up to S1,500.00 anNot imprisotm>wt of up to one year and civil panitica in the focm of a Stop Work Otdcr and a
firm 01 5100.00 a day against me
For dq-rtm a uao city
Permit Number
Malst t#
Si »ite of Liccsxlpermittee e L
SECTION$ C6"' RIlCT10NISERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : IV U \r— hn CL.I--) VNA
License Number
Address Expiration Date
Signature Telephone
- gig
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE,AFFIDAVIT(M.GsL. 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 % �;
r ,
S CTION;fS 3D C�Rf O �+�FuPR POSED�VNOF�K� h ck�all3a licable
KI'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofin
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Wor
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet❑
s" lete a fol la ri I-New O 09 MBLOW d_Xistinh0f i'hM
a. Use of building : One Family Two Family /X 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
SECTION 7a OWNERAUORIZATION
TO BE COMPLETED WHEN
OWNRSAGEN1O�CONRACTOR APPI_IS 1 ORBUIL'bING PERMIT
as Owner of the subject property
hereby authorize _ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized 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 the pains and penalties of perjury.
Print Name
Signature f Owne gent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO L CK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Font
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 X 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:
_-_C*t of Northampton
tng Department
212 Main Street
r !�oom 100
NOV
lLN wit
rtipton, MA 01060
phone 413;5871240 Fax 413.587-1272 - `
A.RjUGATION-TO CONSTRUCif, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: g This sec:#ion#o bek plat
r/ 4 d51v _ wfY
=Maps
ao
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EIm:StDist"riot � f� CBR stt`ict" ���`. x,
SECTION,2-,PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone c.�---
Signature 3
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SEC710N.3 ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars) to be Official Use Only'
completed by ermit applicant
1. Building , d (a) Building Permit Fee
2. Electrical `1 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) 9C) 6 . oo lCheck Number
This Section For Official Use.Only
Building Perin',it;Number; Date Issued:
SDtur
Bu,i ldmgrComrpissloner/inspector of Buihtigs, Date o '
AVE BP 2003 0451
GIS#: COMMONWEALTH OF MASSACHUSETTS
9 17312 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003-0451
Project# JS-2003-0765
Est. Cost: $400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 13634.28 Owner: MENARD ORVILLE E&NORMAN E
Zoning URB Applicant: MENARD ORVILLE E & NORMAN E
AT. 25 GARFI ELD AVE
Applicant Address: Phone: Insurance:
25 GARFIELD AVE (413) 584-8218 O
FLORENCEMA01062 ISSUED ON.11 11102 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P & S H I N G LE 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 11/1/02 0:00:00 302010 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo