17C-081 O
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORICEWS COMPENSATION INSURANCE A.FMAVIT
with a principal place of business/residence at:
(phone#) ��s \fie`
(a-treedcity/statelri )
do hereby certify, under the pains and penalties of perjury, that:
(>f I am an employer providing the following worker's compensation coverage for my
employees working on this job:
ansu=ce 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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compatry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiocal shcc(if nocc=uy to include information peruLiuing to all om tra r3)
( } 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 whilo homeowo=who cmplay p.=om to do nmiajcn.n�cr.lion or repair work ou a dwelling of
not more than throo traits in winch the homoowner residd or oa the grounds appurtenant tberdo arc not gcnUally coasidacd to be
cmploy o unda'the-mkces.c=vcns4oa Act(GL152,ss 1(5)),application by a homoowmcr for a Eo=c or pc m2 may cyi&n=the
legal clams of an employor under the Workcez Compomation Ae<
I understand data copy of this=Wcmcat may be forwarded to tbo Depuuooz of Indarstrid Acci&-f>O1Soo of lust snoo for the
oovetage verification and that failure to so=coverage under section 25A of MGL 152 can lead to tbd impomdioa of a—*'penalties .
comihig of a fine of up to S 1.500.00 and/or imprboomwi of tip to one y=and civil pcml ics is the form of a Stop W ork Order and a
frno of S 100.00 a day agaiuA the
For dernctmx"i use only
Permit Number
, r 41
SE 8 .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : );�VVI:Cll &, IN4�'}.
License Number
Address Expiration Date
Signature Telephone
Fte re Name:: mgr v�emen n r r � _. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone 's
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
RUN,
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,
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 he 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
#�' s §yN"'',d "°"" ° v. •; am z a
-SEC 5 D GRIP � � APR PO D'►WOR c ` I�a h'cable
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors I&.
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:—�. j\
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes ✓ No
Plans Attached Roll 0• Sheet 0
ca1 f `e h &Yrd- o ddft�toexis iW-,, dusin Com,l:efie' fhe M1..a" 'i :
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? , r
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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION Tea, OWNER AUTHORIZATION JO BECQMPL'ETED .WHEN
OWNERS AGENT OR CONTRACTORAPPLIES FORBUILDING 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
Q , as Owner/Authorized Agent
her b)declare that the statements and information on the foregoing application are true and accurate, to the es o my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
S' nature of Owner/Agent Date
s '
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:
City of Northam,ptotY
Building Department ? ,
212 Main Street''
Room 100--:,/
J
Northampton, MA'-t 06Q� J=`
phone 413-587.1240 Fd.;e413-587.1 r -
r
Z
APPLICATION TO CONSTRUCT,ALT ER,°RLP.AIR,.REN $ OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 11-SITE 1NFORM.ATION.
1.1 Property Address:
Zone= O_e a
Q � ,'
Elm, t Di str �
� et �
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of �Record: 1�
Name(Print) Current Mai ddress:
Telephone
Signature
12.2 Authorized Agent:
Name(Print) Current Mailing Addres
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION 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 =(I + 2 + 3 +4 + 5) Check Number
This Section For.Official Use Only
Building Permit Number: Date Issued:
Signature:.
Building Comm'►s`sionerllnspector of Buildings_ DateF;
BP-2003-0538
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
woopm-
Lot: -001
Permit: Building?
Category: windows replaced BUILDING PERMIT
Permit# BP-2003-0538
Project# JS-2003-0430
Est.Cost: $2600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GroMaj- Kevin Netto Construction Inc. 103948
Lot Size(sg. ft.): 17903.16 Owner: CAMMY JUSTIN
zoning:URB Applicant: Kevin Netto Construction Inc.
AT: 41 HIGH ST
Applicant Address: Phone: Insurance:
90 Southampton Rd (413) 527-3168 Workers
Compensation
WESTHAMPTONMA01027 ISSUED ON:1214102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 12/4/02 0:00:00 2542 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo