17C-068 (9) t'O e -
a 6 �asarirE(ncrlla' —0
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
IrTorthampton, Mass. 01060
W COMTENSA SURANCE AFF DAWr
(lice permi ttcc
with a principal place of iness/residen at:
(strc nP)
do hereby certify, under d enalties of penury, that:
( ) I am an employer providing the following worker's cornpelisation coverage for my
employees work�ng on this job:
(ln"1=C_— 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) (Lnsurancc Company/Policy Number) (Expimtdon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsuranc�t Company/Policy Number) (Expiration Date)
(Name of Contractor) ansZirance Company/Policy Number) (Expiration Date)
(attach addiboair ssccf ifn<cu.xy to i�cludc mfonnatioa pertaining to all ooabmn r3)
i
am a sole proprietor and have no one worl�ng for me.
( ) I am a home owner performing all the work myself.
NOTE:pteaae be awart that wixile homcoµ,vcra who employ priors to do mzualcraacc,case rust oa or repair work oo a dwelling of
not moot than threo units in wtuch the]wmcowncr residca or oo the uviads appu�thacto arc oot wally ooasi&rrd to be
employes under tlx wor<ct s=r t�cn Act(GL152,1:3 1(5)),apptiration by a homcocrna for a license a permit rney evidence the
legal ctatua ofan employer underthn Workcea C.ompomaiion Act
I uadcrs d that a copy of thu rzatcmcnt may bo forwarded to tho Dcpartnmt of Iodauhial Acada>&Offroe of In�£or the
coverage verification and that ftdtmr to scat coverage undo 25A of MOL 152 can lead to tho unposdion of criminal penalties
oomisiirrg of a fine'o 00 artdlor imprisonm� up to year and civil penalties in the form of a stop Work Ord,and a
fu>A of S a day ag�tirast
t dp-trn-ell uac oaty
permit Number
1)4{ Lot#
h , of Liccnsrr/P� ' ter.
SECTION.8'-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
06�'�n�%
Address Expiration Date
Signature Telephone
K �.. tee. rM� ..,H Not Applicable ❑
RegiteredHorrie Irr�provemertCon tr`actor = � K__. a
Company Name ! Registration Number
Address Expi a ion a
Tel hone
SECTION 10-WORKERS''COrVIRENSATIO "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 affil,
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
9 EW
�.1.�-�H,ome�O�nerr �xempt><on
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 faun
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
SECTION 5='DESCRIPTION &-yROPOSED WORK(check all applicable) ,
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing El Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] D cks [ ] Siding[ ] Other [ ]
d
Brief Description of Proposed Work: A—
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a -lf-,New',house aridsor addition to isfin housing, com let&''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 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
" 1 PA4,uth orized Agent
hereby decla e t ffrt statements a d irlTorm5lion on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pa alties of per u
!�
rint Name
;igra of caner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
"rhis 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:
y �
City of Northampton Sta s f P r i
Building Department
212 Main Street SeweSept�c aalab
Room 100 W✓ er�WAvalblli __
Northampton, MA 01060 wo Sets ofStr
phone 413-587.1240 Fax 413-587-1272 PIotlSltel'lans � s ,
Others ec�f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section,to be"completed by office .
1.1 Pro pert Addres
Map Lot Unit
-Zone Overlay,District'
Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr' t) / urrent Mai ng ress:
e �
Telephone
Signature
2.2 Authorize
Name(Print) t ailing ddress:
Signature ` e epho
SECTION 3 - ESTIMATED'CONSTRUCTI 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 =G + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Bui ding Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date'
ft991T ST. BP-2002-0316
GIs#: COMMONWEALTH OF MASSACHUSETTS
x ,Block: 17C-U6Zi`'` CITY OF NORTHAMPTON
Lot:-001
Permit: Buildina
Category:windows replaeed BUILDING PERMIT
Permit# BP-2002-0316
Project# JS-2002-0481
Est.Cost:
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouo. Robert Thibodo 118441
Lot Size(sq. ft.): 27834.84 Owner: JEROME KATHLEEN F&
Zoning:URB Applicant: Robert Thibodo
AT: 145 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON.•912010I 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOW
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 9/20/010:00:00 7658 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo