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DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMTENSATION INSURANCE AF MANTIT
1,
(liccnserJpermittcc)
with a principal place of business/residence at:
(phone#)
(street/city/staffhip)
do hereby rtify, under the pains penalties of perjtl that
( ) I am ' e ployer providing e following worker' c mpensation coverage for my
employee wo ' g on this job:
c-- mpany) (Policy N tier (Expiration Date)
O I a sole p prietor, eneral contractor or h meo er (circle one) and have hired
the cqn actors li belo who have the follo g work I's compensation policies:
C of Contracto ) (Insurance Compa y/Policy N r) (Expirtioa Date)
.,
ame of Contractor] (insurance Company/Policy Number) (Expiration Date)
ame of Contractor) (Inl=et= Company/Policy Number) (apimbon Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(attach addldoail sl)'-ct ifneceaary to ioclude infbrm oa pertaining to all ooa rn.dots)
i
O I am a sole propriclor and have rin one,, workiing for me.
X am a home owner performing all the work mys
N :p to do mnmtm—cr,w� oa or repair work on n dwelling of
not morn than(firer units in which the homoowoer resides or.,b,grounds appurtenant thacto ere not gcacralty coandard to be
cmploycrs under the worms ampcnsatioa Ad(GL152-a 1(5)�application by a homoow ncr for a license oc permit may evidcam the
legal datur of an omployoc under the Wocicor'c Compomatioa Act
I understand that a copy of this rim t—ii may bo focwmijad to tbo DW ti, n of lr&sttid Accidents'Office of In t—foe tho
eoverage vaif cation and that failure to socure covecago under soctloa 25A of MOL 152 can lead to the imposition of aimi peaaltiea
oomittiag of a&ne'of up to S 1,300.00 and/or imptiso of up to one year end ci vil penalties in the form of a stop Work th dtz and a
fum of 5100.00 a day ag&iust mo.
Foe depa�al uao only
/ permit Number
#
ignahtre of ccnsec/Permittee
SEC. N2 .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: w Not Applicable ❑
Name of License Holder :��_ �- ����� C✓" d / Y�2 /
License Number
Add ess 2 Expiration Date
n , 3 /
ignature Telephone
Re>ristered Home Im rovemenfCbntractor�'
y �
. .�� i €per Not Applicable
r
Co many 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 affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No......
1 �° H.om� ®caner xeml). I
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 buildine 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
SECTION 5 DESCRIPTION OF PROPOSED'WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Add Se G
Alteration of existing bedroom Yes X _No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes X o
Plans Attached Roll ❑ - Sheet❑
6a If NeW house and or:addition to`exist'ing; Housing; comp1et6,Ahb'following
a. Use of building : One Family Two Family Other
b. Number of rooms in each family nit: Number of Bathrooms
c. Is there a gara attached?
d. Proposed Squ j-e footage oFewconstructi Dimensions
e. Number of sto ies
f. Method of hea ing? Fireplaces or Woodstoves Number of each
g. Energy Conse atio C mpliance. Mascheck Energy Compliance form attached?
h. Type of const uctio
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 7a �OWNERAUTHORIZATION -MBE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES;FOR,BUILDING PERMIT
o as Owner of the subject proper
hereby authorize lam' a /' 1/ ) I` de to ac:
my behalf, in all matters relat t6 work a orized by this building permit application`.
Signature of OwVer Date
4 A as Owner/Authorized Agent
hereby declare tha4 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.
6- At y hZo Al
Print Name
v/
Signature of Owner gent 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
1
Frontage
Setbacks Fro t
Si L: R L R:
i
fir
1
Building H i�ht
Bldg. Squ rib Footage /o - )i
Open Sp Footage
(Lot area m us bldg&paved
parking)
#of Par ing Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO t)( 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 X _ 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:
,.....,.,v,.,..„,_.,,V. ,_ ._....
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City f rthampton StattiskofkPem�
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JUL 16 Ma Department Curl)`Ul'
2 2 M iin Street Se�werlSepttcAva�lab
Roo 100
DEPT Or suatsG INSPECTIONS WaterlWell Avatlability a
NORTHAMPTON,MAa n, MA 01060 Two Sets of=Structural�a s ��
phone 413-587.1240 Fax 413-587-1272 PIotlSite Plans� �
a agH l Xss
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I - SITE INFORMATION
1.1 Property Address:
This section to'be completed by office,
)
/ C �,e sT AIW/ SI— Map Lot Unit
Zone Overlay,District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(Y A,_)( 4 c/>zA,/ _ �r CaAe.5rN f r S%, � 10 C-A/C_-
Name(P(int) Current Mailin Address:
��-✓ Telephone
Signature
2.2 Authorized Agent:
S'hM t�--
Name(Print) 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 i — (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from b
3. Plumbing ,/ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /VA
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
"V, BP-2002-0053
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Category:roofing BUILDING PERMIT
Permit# BP-2002-0053
Project# JS-2002-0073
Est. Cost: $1200.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Sizes . ft. : 10541 .52 Owner: WORDEN GARY C&SANDRA A
Zoning:URB Applicant: WORDEN GARY C & SANDRA A
AT. 91 CHESTNUT ST
Applicant Address: Phone: Insurance:
91 CHESTNUT ST (413) 584-3241 (�
FLORENCEMA01062 ISSUED ON 71161010:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING ONE LAYER
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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/16/010:00:00 2038 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo