17C-068 (10) a Gkf� Jof 'Wax#liantpton
a _
�assacllnt:clta
IL OWN
t12 PARTMENT OP BUILDING INSPECTIONS
oIpt,G I SPECV)t""=' Main Street ' Municipal Building
MA 01060 Northampton, Mass. 01060
W0RICER'S COMPEN ON INSURANCE AF MAVIT
(li Cmscdpermi ttcc)
with a principal place of bUSW' CSs/reSlden at: f
7 71/, 7;f
(st7r�.t/ci h-/spa trl�p)
do hereby certify, under the pains and penalties of perjury,
O I am an employer providing the follo\ving Nvor�er's compensation cover age for my
employees wor-Lng on this job.
(Instuance 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 workeA compensation policies:
(Name of Contractor) Qmsuranc-- Company/Poky Number) (E)cpiratioa Date)
(Name of Contractor) (Insurancz Company/Toney Number) (Ex-piratioa Date)
(Name of Contractor) Omsuranc-- Company/Poticy Num�r) (Expiration Date)
(Name of Contractor) (Insuianc-- Company/Poky Number) (E)cpiration Date)
(ansch additiooal shoct ifnocxa to incl do informtEoo pertaimng w.11 ooa raclnn)
am a sole proprietor and have no one worEng for me.
( ) I am a.home owner performing all the work myself.
NOTE please be aware that whilo homcowocra who employ perzons w do amjat,-,,x m¢z ruction or repo it work on a d.vclling of
not more than throo tails is tvbich the bomoowocr rcida or m the goun sppurtctlarrt thacto arc oot gcoa-ally ooasidcr d to be
cmployas under tha workcc"0=9caLdicla Act(GL152-m 1(5)),application by a bomcowncr for a lic=e cc pamii may cvidcocc the
ltgal cta2us of an employee uodorthe WorkCes ComVeoaatioo ACL
1 uo&r"Aad that a copy of thin c f—d may be forwarded to tho Dctwrtmaod of 1o�d Accdtaaf offs o of lavu.nw for the
00vaszc vcr f'cstioa and that failure to scam(:coventso under section 23A of MGL 152 can lcsd to tbd impos—of aimi ml pcuultica
oomittistg or a,fine of up to S 1.500.00 and/or' of up to one year and civil pcmdtia in the fours of a Stop Wort Otda acid a
5no 0(5100.00 a day tpiast me
For dcpatnral tun only
Permit Number
Nfap4 Lot{!
Signalurc of LiccnscxlPczmittec
r.
-`001 'T.UCTIOK,SERVICJEISI�
a.1 Licensed Construction Su ervisor: ��' Not Applicable ❑
Name of License Holder:
License Number
Address ! Expiration Date
Signature Telephone
Not Applicable ❑
Company Name ) Registration MAImber
Address Expirati.d'n Date
S IV, tN'412f€R . 7ESN iNSURNCE AFFtaAYS' M 6 ECTt I� G . c C })
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.
;ned Affidavit Attached Yes....... No...... ❑
W! ",My
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
CT ESCRCPTI.ON OF'PROPf3SED 41&4R1F;. 0hck=aft,anolcahfe)'
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing��
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 6
Alteration of existing bedroom Yes NoAtddi new bedroom Yes ` No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet 11
mmwaw ft- a I& �'Cgwfyt'
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?
.. 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 -OWNER AUTHORIZATION -TO BE CGMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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
I, Authorized Agent
hereby declare that the statements arrd 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 Na 1
Signature of-QwmTr%Agen Dat
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:
i -Northampton
�' R7 i I epar tment
2 lain Street
10 � s m 100
North mp,on, MA 01062
pEppRTO gQPQCI , -1 40 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
st CTIQN T-SITE INFOOMATC0111
"I Fri rn}tie
1.1 Property Address:
9 t a s r 4
$ Rm
#E
SECTION.2,�0 ROPERTY 01f ERSllll /AUTHOW 0 AGENT
2.1 Owner of cord: , .
Name(Print) Current Mailing Address:
Telephone ff,�
Signature
2.2 Authorized ABC:
( �f 3D
Name Pr' Current Mailing Address:
Signature Telephone
AT
SECTION 3 ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a) Building P�errnit Fee
2. Electrical (b) Estimated Total Cost of
Construction from: .5y
3. Plumbing Building3Permifi Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check:Number
This Section For Official Use Only
Biile{ing,Permit Number: D/off o Date Issued;
Sign tun:
Building Commissioner/
Inspector aF:Buildings- Date.
145 CHESTNUT ST BP-2001-0020
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17C-068 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0020
Project# JS-2001-0038
Est.Cost: $5835.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT D THIBODO 118441
Lot Size(sq. ft.): 27834.84 Owner. JEROME KITTY
Zoning Applicant. ROBERT D THIBODO
AT. 145 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-8966
NORTHAMPTONMA01061 ISSUED ON.7/10/00 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF & NEW RUBBER ROOF
ON PORCH
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 Tyne: Receipt No: Date Paid: Check No: Amount:
Building 7/10/00 0:00:00 7053 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo