17C-092 (10) 4-'C1iAMPTO
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DEPARTMENT OF BUILDITNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee)
with a principal place of business/residence at:
i s a z� ��?p , (phone#) z s6- /bob
(street/�ty%statr/riP)
do hereby certify, under the pains and penalties of perjury, that:
MI am an employer providing the following worker's compensation coverage for my
employees working on this job:
20-3,5-71
(`ran-1V- X5. 6 . 064600y 6-l9 -o2
(Lammance Company) (Policy Number) (Expiration Date)
(�C) 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:
Ain- Pn� f o,g'
(Name of Contractor (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml zhcct if necrssrry to include information pertaiaing to all ooatr ifs)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myselff.
NOTE:ptcaso be await that whilo homcowucca who Mplay pc=m to do maint.caaacc,caastru oa or tcpair work on a dwelling of
not mote than three waits is which the homoowucr resider or on tb a grounds apputtcnani tbarto arc not gc xrally weiWemd to be
employes under the works' s4on Act(GL152,ss 1(5)�application by a homeow=fora license oc permit may evidcnoe the
]cgal ctntua of an employer under tin Wort t C.ompemation Act.
I undasitud that a copy of thin rhicmcni may be forwarded to the Dcpart nm of Iodus 'J Ac6dmt,'Offioe of Inwr+noo for the
covaago varificatioa and that failure to&enure covmv under section.25A of MGL 152 can lead to the imposition of ak3kd penalties
oomittiag of a&no of up to$1,500-00 andlor kMPr sonmctt!of tip to one year and Civil panttia in the form of a Stop Work Ordc and a
fi>m of S 100.00 a day against t>x
JJ
For dq=tmmtal—�y
Permit Number
` tu, O Lot#
n Signnture Licen.�Permittee 1
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e Not Applicable ❑
CA✓ A5 K - CNf-IJ
Company Name Registration Number
dba/ 1�-t� 5 s; F.vC ouL,x to 89 76
Address Expiration Date
22a Telephone 256–/(00 6$/ Z8 266 2
SECY ON 10 IVORKERS' COMPENSATION ItJSURANCE AFFIDAYI,T(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...... ❑
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 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 Dj�Qx_�./ 11,19 —
a
New House ❑ Addition ❑ Replacement Windows Alteration(s) P4 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
� � °•
Brief Description of Proposed Work: ' (IN c 1$ a
Alteration of existing bedroom Yes_ X_No Adding new bedroom Yes X No
Attached Narrative❑ Renovating unfinished basement Yes A No
Plans Attached Roll o- Sheet❑
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
,K� i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes I
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
IZA�ON8 Cf) ED &W1 >=
e
I _ as Owner of the subject properl
hereby authorize U to act
my behalf, in all matters relative to work authorized by this building permit application.
':�)2 .1 a F1
Si gnat of Owner Date
I 3-r- Et/E' �"1�'U l)C / /�,'->'gwi�,j5 44 -1--fg,6rJ as Owner/Authorized Agent
hereby 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.
Print Na
g_p
Signature o ner/A nt Date
s
K
t
Section 4.
ALL INFORMATION MIDST 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_ X 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 X _
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:
ity of Northampton
Building Department
212 Main Street
ALIG - 9 2001 Room 100
Owthampton, MA 01060
phonk411587-1240 Fax 413-587-1272
DEPT Of BUILDING INSPECTIONS
NORTHAMPTON.MA 01060
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SI=CATION 1 ' 1TE�NF�Of l lie►T 61
1.1 Property Address: ;
Z 2 � n of oC a
r T r-)a YY' r�
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZEf)AGENT.
2.1 Owner of Record:
i'YIAv,eF5.J ✓n oghil -r� I22 c� 54-ho-
Name(Print) Current Mailing Address:
- 413-58 f-787-S
Telephone
Signa ure
2.2 Authorized Agent:
j u 3 �2m�S 1912711
Name(P ' ) Current Mailing Address:
413- 251, -1Lo6
Signature Telephone
rY�'.� Ak' ,
SECTION 3.-'E5`TIMATEOCOISTRt1CT10N;C�5T5'
Item Estimated Cost(Dollars)to beOf#�c�al Usnty
completed by ermit applicant
1. Building
�=(a)'Buildirg Permi#fee
2. Electrical (b) Estimated Total Cost.of
Construction,frorrTF(0
3. Plumbing l C0 Building,PermitFee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 1 S' 6Z. Check Number
This e,ctiom=For.OfficialUse,O"nl
$ itdlrterm' Nrrtber Datelssued
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.k ?3rL1I(ItigQ171r)115 �Qi�,r,,,,spect0rof l3tt>i�rBs 3.. �.3,bM ,r
i
File#BP-2002-0156
APPLICANT/CONTACT PERSON MORIARTY MAUREEN
ADDRESS/PHONE 122 CHESTNUT ST (413)584-7825 Q
PROPERTY LOCATION 122 CHESTNUT ST
MAP 17C PARCEL 092 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid X&I 40
Typeof Construction: INSTALL NEW CABINETS&COUNTERTOPS(UPGRADE ELEC&PLUMB)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
4 k" �, _del-e, Z
Signature of Build' Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
z =tr
BP-2002-0156
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0156
Project# JS-2002-0247
Est. Cost: $5700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sic. 1): 7013.16 Owner: MORIARTY MAUREEN
Zoning:URB Applicant: MORIARTY MAUREEN
AT: 122 CHESTNUT ST
Applicant Address: Phone: Insurance:
122 CHESTNUT ST (413) 584-7825 O
FLORENCEMA01062 ISSUED ON:8110101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW CABINETS & COUNTERTOPS
(UPGRADE ELEC & PLUMB)
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 Siiinature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/10/010:00:00 7046 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo