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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 o,~
WORKER'S COMPENSATION INSURANCE All iAVIT
~7�- ceusee/ ttee
with a principal place of business/residence at:
_ (phonei#)
(str e city/stafrhip)
do hereby certify, under the pains and penalties of perjury, that:
( I am an employer providing the following worker's compensation coverage my
emplo working on this job:
rte.
(Insurance Co ) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, g eral contractor or meowner (circle one) and have hired
the contractors listed below who ve the fo wing worker's compensation policies:
(Name of Contractor) -cc CorrylPolicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy umber) (Expiration Date)
N
(Name of Contra (Fpiron Date)
c
(Name of Contractor) (Insurance Company/Policy Number) (Expir Lion Date)
(attach additional sheet if nccas-xy to inc}ucie information pertaining to all ooatra'don)
( ) 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 homcowo=who cmplay pa-w=to do m adc r,cowt%=oa or repairµuric on a dwelling of
not atone than three units in which the homeowner raids cc oa the grounds appurtenant thereto ntc cot gay coosukrod to be
employto undo the woticcs's Galion Act(GL152,ss 1(5)),application by a homeowner for a liccax or permit may evidence the
legal etztu of an amploya under dw Workeet Compematioa Ad.
I understand that a copy of this zEatemeat may ba forwarded to the Depnrtmrni of Industrial A,=&-s'0f5oo of 1nauaneo for the
covaxge verMcalioa and that failure to sauce coverage trader soctioa 25A of MOL 152 can lead to tba"imposition of-mind penalties
oomist=g of a Sao of up to S 1,500.00 and/or�of up to one year and civil penalties in the form of a Stop W oric O[dcr and a
fins of 5100.00 a day against me.
Foe degsrtmed'1 ease only
C. Permit Number
Map4
Si hire of Licensee/Permi e
SEC,T,IQ�f$,-;CONSTRl7CTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
2t4, License Number
Address Expiration Date
Signature Telephone
E Not Applicable
Company Name Registration Number
2-
Address Expiration Date
t� Telephone
SECTIQN 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§ 25C(6)).
Workers Compensation Insurance affidavit must be completed an u mitted 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...... ❑
g
In
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-vear 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(( d ocal Zoning Laws an State of Massachusetts General Laws Annotated.
�Homeowner Signature /�C // �'G
SECTIONf5�D1ES0 �P=,ION OF`PROPOSED WORK he k4 a
==+�' licable
rrpd iHYfi�au3 W4t ..A°tk ."c
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ��2
Or Doors ❑ j/
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes L- No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
Ca if ew house nd�or tfd`ditJdhl o exis11 fikJT6 §ink r-cbffiPIbte the 611dWi":
a. Use of building : One Family Two Family Other
b. Numb� 000m_s in each family unit: Number of Bathrooms
c. Is there a garage attache`d7---
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
rrs''
f. Method of heating? � eplaces or Woodttwes Number of each
g. Energy Conservation Compliance. Mascheck Energy Compli ce form attached?
h. Type of construction `�•
i. Is construction within 100 ft,,) 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 COMPLETED WHEN
OWN>�FtSGENIORCONTRACT.OR APP_LIES, FORBUILDING PERMIT
< as Owner of the subject property
' � h
hereby authorize to act on
my behalf;' al;`matters relative to ork authorized by this building permit applicaJon.
Signs ure of Owner Date
I,
as Owner/Authorized Agent
hereby declare that the stateme' is and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed and the pains and penaltie of perj�y.
R \ C}
Print NA fie
0
Signatu e oi Owner/Agent Date
I
. 1
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: `f V',R: L: R:
Rear
Building Height N
i
Bldg.Square Footage f°
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parkin .$paces 41
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on he 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 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 here any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
City of Northampton
Building Department
— Main Street
V
ROOM 100
D �'" —' h rnpton, MA 01060 {
phone 413 1240 Fax 413.587-1272 P
'-w
TRU T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
NORTRAT41?0N,MA 0;060
SECTION 1-SITE INFORMATION
1.1 Property Address: This section:to b �completedaby�o 1c�e�
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�17�. ' Map
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g Zone��, St ICt ' $ s
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— Eltti`St:`District �� ;CB Disnct ._ ?
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�1
a - S�' Sze
N (Print) Current Mailin Address:
Signature -
2.2 Authorized Agent:
N (Print) Current Mailing Address:
' s ctll�
Signature Telephone
SECTION 3i- ESTIMATED CONSTRUCTION COSTS
Item` Estimated Cost (Dollars)to be Official Use Only
B completed by ermit applicant
1. Buildin dC �, �, (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 C,1
6. Total =(1 + 2 + 3 + 4 + 5) 0 _ e,C', Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
5,lgn6tuee:
Building Corrimissjoner/InspectoX,of„Bytldings Date;-.; '
BP-2003-0242
GIS#: COMMONWEALTH OF MASSACHUSETTS
=114 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0242
Protect# JS-2003-0424
Est. Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor_
Lot Size(sc. ft.): 11979.00 Owner: RICE ROBERT T&NANCY FABIAN
Zoning:URB Applicant: RICE ROBERT T & NANCY FABIAN
AT. 50 STILSON AVE
Applicant Address: Phone: Insurance:
50 STILSON AVE (413) 586-28610
FLORENCEMA01062 ISSUED ON.919102 0:00:00
TO PERFORM THE FOLLOWING WORK:STR I P, PLY & S H I N G LE GARAGE ROOF
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 Sisnature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/9/02 0:00:00 3074 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo