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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A_l1MA AVTT
I,
(lice�5ee/permitzee}
with a principal place of business/residence at:
(phone#)
(streeUci ty/staf rla p)
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)
(Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(&Mach additiooal shoot if n6o=miry to inchUde mfonnibon pertaining to aIl ocatraclon)
O 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 while homcowncra who employ pczza=to do m,_*�o=stixtion cr rcpair A-ork on a dwelling of
not more than thrm units is which the homoovrmcr resides or oo the grounds apptuten ibacto art n«gc craily 000ndcrcd to be
cmptoycn tender the wm-kc a ooatpcusatioa Act(GL152,s 1(5)�application by a homcowocr for a liccux or permii may cvidcaco the
legal rtahu of an employer under the Workeeg Compomalion Act_
I under& d that a oopy of thin rtatcmcat may bo forw=xW to tho!?cpatt of Ind,u0ri a1 Acrid Oiijoo of Invert n for tho
coverage vcrifitxtioa and that failure to secure cova&V undcr soction 25A of MGL 152 can head io the imposition of criminal penalties
coasistiag of a fine of up to S1,300.00 and/or imprisoamcat of tip to one year and civil pcnaltia in the form of a stop Work Ord--and a
firm of 5100.00 a day against mc.
For dgrartmedal Mao oily
6r'n per mit Number
1Map t Lot#
Liamserlpermitlee e
�Pi b �i ' 33 3}- �q 'as°3', ' , o-3
U pN��� C�I 35TR0� 1, N�5�E#t1lICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company 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 affidE
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)familic
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
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
77 } 777,
SECTION D SCR PST PROPO�SEDIR� : a 1 a #tica�ble '3. ,,yy}:?
'S9bx #' Y« xalN 4fb F' SM k'E
yk,"m� .. ... ..
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing *�
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ri e p A.t P 12.e,
Alteration of existing bedroom Yes_ No Adding new bedroom Yes _No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ Sheet❑
?INN e M'diti P06z191,th h0u"sin Arnim "fie e fully ,
a. Use of building : One Family Two Family Other- /V
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
SCTONa DOWNER AUTIORIZATION TOBE COMPLE73ED WHEN
O1NN>=HS AGEN ,&QR CONTRACTOR AP!PI.IES, OAR Bt11�DNNG'P RMIT
as Owner of the subject proper
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereb 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.
Pri to Name
Signature ft oeru oeru Owner/Agent Date
i r
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 Ll
Setbacks Front V —�/
Side L: 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 L-� 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 z/ 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:
U I 5nt mpton
B e rtment SEP 2 4 treet m1 0 DEPT 01 BUILD pton, A 01060
M b x 413-587-1272 o#l,le
C1t�h5peci�:
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectionAo be com le#ed> y of ce
1.1 Property Addres ,
L. ry►a I of
OK
Zone OuerlayDistrtc# �
a;
g
Elm St. District CBDistnct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ab tk P LAI/
Name(Print) Current Mailing Address:
Telephone f --
Signature
2.2 Authorized Agent:
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 o2 (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 = (1 + 2 + 3 + 4 + 5) t Check Number
This Section For Official Use Only
Building Permit-Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date .
`40 sr BP-2002-0331
GIS#: COMMONWEALTH OF MASSACHUSETTS
"iqg): I7c'-096 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofin BUILDING PERMIT
Permit# BP-2002-0331
Project# JS-2002-0503
Est.Cost:$225.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 31842.36 Owner: WHITMAN ROBERT D&CHRISTINE R
Zoning:URA Applicant.• WHITMAN ROBERT D & CHRISTINE R
AT. 140 CHESTNUT ST
Applicant Address: Phone: Insurance:
140 CHESTNUT ST (413) 586-1537 O
FLORENCEMA01062 ISSUED ON.91261010:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE ROOFING
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 siiinature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/26/010:00:00 522 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo