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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ,y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
;' ,(ltcensee/permlttee)
with a principal place of businessVp6sidence at:
dcuL;
do hereby certify, under the pains and penalties of perjury, that.
( ) 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) (lnsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (I.n_surance Compauy/Policy Number) (Expimdon Date)
(Name of Contractor) (IasZlraace Company/Policy Number) (Expiration Date)
(attach additional slxct if neccns y to include information pertaining to all Qa� Ctora)
((}<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 awns that while homcoA1)eT1 who crnploy pGZOrs to io e aiatcainc�ma action es rcpau work on a dwtlling of
not mote than thrco units in which the homcoµixr rczidcs or oo the FTourYL zpµirtetiant tbccto arc not G—rzlly ooatidcrcd to be
employers under the workct's ocarp matiou Act(GL152,ss 1(5)),application by a homtowncr for a license or permit may cadence the
legal etatu of an omployor undertho Workels Compo wAion Act
I uodct s d that a copy of this ctatcmcat may bo fbrwnrdad to tho Dvwtmcnt of Ind+i:d ial Ao6&r 2 Offioo of Im—'Dc for tho
coverage verification and that failtire to secure coverago under—tiou 23A of MOL 152 can lead to the imposition of criminal pcnaltict
ooaustmg of a fine of up to S 1,5oo.00 anNor im{xrsoanxa2 of up to one year and civil pcnaitits in the form of a stop Work Order and a
fiat of S 100.00 a day against fix.
. n For dcputnrsrtal use only
Permit Nttmber
Wp;l Lot
SignabIre of Li e tee
SECTION 8-`:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�' o ram"'wxettnr± :_:° ....,,• - ,�, s ..uk' 4 ar +
9Registere�ENbme�lmprovement'Contr`actgr• „ _ �� �.�* �.,�,�,a_ __.� 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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1R1�- e 7Wng. getup on.
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.
—,IzHomeowner Signature
SECTIONS DESCRIPTION OP PROPOSED WORk-(check all applicable-
..,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑ �!1 �✓/ ��
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ J Other [ ]
Brief Description of Proposed Work: 4 >>./_1/ =
Alteration of existing bedroom Yes No Adding new bed om Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet
64 JVN, nr hdU§&4id oFV6dditi6b to existingjfiousing; cornpl"ete ttie following
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
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 COMPLETED 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, 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�Naamme�, e
Signature f Owner, Agent Date
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 KNOV /\ C
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 w
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:
.1P w
lof Northampton S
u ing Department r
2 Main Street°
JUL — ^CO2 Room 100 a e e a
N rtha pton, MA 01060 et :c:f c
_ _Oho.ra& 587 1240 Fax 413-587-1272 Plot1S p a
` INSPEOf!ON �
P,E°T pf Isli'l�^�G+.R Q1CnO Ot�'ter�SpeCt.� ����
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to beTcompleted by office
1.1 Property Address:
�,. fVfap lot 1JnIt
/Ls` „/
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bvq
P
o , Zone Overlay Distr�ctj p
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e
Elm St. District CB District"
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -7
yy -z A/AA 0,1/
Name(Print) Current Mailing Address:
Telephone
Signature'
If
2.2 Authorized Agents c '
to
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
com feted by ermit applicant
1. Buildin (a) Building Permit Fee
2' ectricai (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) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
I
,
BP-2003-0027
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: B u i l d i Z
category: BUILDING PERMIT
Permit# BP-2003-0027
Project# JS-2003-0087
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group Homeowner as Contractor_
Lot Size(_sq. ft.): 11238.48 Owner: JOHNSON CARL F&MARGERY T
zoning:URB Applicant: JOHNSON CARL F & MARGERY T
AT. 32 STILSON AVE
Applicant Address: Phone: Insurance:
32 STILSON AVE
FLORENCEMA01062 ISSUED ON.718102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/8/02 0:00:00 1536 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo