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17C-108 (6)
0?E (r It ) cif � ,To fljalilptoil DEPARTMENT OP BUfLDlNIG INSPECTIONS — 212 Main Street ' Municipal BuildinG Northampton, Klass. 010GO WO CO\TPENSA`IION LNSLTWCE AFFIDA�TF (li ccuscc/permi tic-C) -- rich a principal place of business/re dente at 1 none:-) 7 7 ( city/stalc12j p) do hereby certify, under the pa s and penalties of perjury, ?hat ( ) I a o an employer providing dic following workers coinoensL ion coverage Cor ln), eluplovees wor�Dng on Lilts job. 0MSu-F---C-- Coo=-,,) — (Pclic: Nu--,ibcr) --- (r :pirarior Date) ( ) I am a sole proprietor, general contractor or homeowner (ci:cie one) and have hired the contractors fisted below who have the foBo%ving worker's Camnensadon policies: (Nam-. of Co:,.!:ncw-) CoinparlyiPohcr Num!Y;) ft.>:)i;Ul:On Datc) (Name of Contractor) _-- (lnsuranc: ComDanyfPohcr Numcrr) (–Expu lion Date) (Name of Conn-aclor) (Insuranc; Compuy[PoLic? NumbeJ) (Expo:tdo❑ Date) (Name of Contractor) (Lasuranc-- Compamy/Pol cy Nuxabcs) (L-xPiraiion Date) (aua['J]-6li;i ocil c'xc2 if o<cti.:� to czK!uc mfortn non P'nn.iains to ail aim a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plc be na-arc th.0 uUc bOQKo O,.t>o cmplay pc-som to do R c -rte r rc,-xiu"Ofk d..<11=g of not mat ihn l! .tau in wt ich the loan -Ucr raido of oo the V-6 n 2apurt"ni Ibcco LT Doc Ec.- Zuy axa:&-rcd to tr cmploym undc t_hc--3-&1_MpCa1im Act(GL152-"1(5)�n4VUCa600 by a bomcowvcr fnr oc pernui n=y nidcooc the ICIPJ rtnau of co-MPloyx undo rho Workoe,Co,�A.t. I undc-laxad that a oopy of this aat.® may bo focwarded to tbo Dcpnnmr_o2 of lru jd Arndmtf Ofrioo of(traui000 for Lb, oovcnsc`rcrif ettiaa MM auj LdLma to toot tio%eMg,under soC OQ 25A of htaL 152 an Icsd to the impasIIioa of criminal PaL L-W- ooau-,a g of a ftnc of up to S 1,500.00 nndlor' of up to one yc Lod a%il pmafUO in be form of a Stop Work Ordcr wd a rim of S 100.0 me For dcp.�uac Drily PCnIIJI Number _ f"55zl ],,,,P",_ Lot " ign nn of Li crmiUcc e - - . h SECTION 8-CQNSTRUCTION SERVICES 8.1 Licensed Construction Su erviso Not Applicable ❑ Name of License Holder 6 License Number_ Addres � Expiration D e Signatur Telephone ;k. ... .); � Not Applicable ❑ � / Company Nam Registration N ber Vd Ad ress ' Expiratio ate Telephone SECTION 10-WORKERS'. OMPENSATION INSURANCE AFFIDAVIT(M`.G.L.c.'152,§',2SC(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...... ❑ 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. Homeowner Signature c New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: 20 Alteration of existing bedroom Yes No Adding new Broom Yes No Attached Narrative❑ Renovating unfinished basement Yes No ✓'� Plans Attached Roll ❑ - Sheet❑ Ow 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? .2= 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 SEC 7a„-OWNER AUTH ,RIZATION-TO H COMPLETED WHEN ©YYNI=R A0ENT CSR CONT '"CT<3R” 'PLII< FOR BUILDING PERMIT as Owner of the subject property r hereby authorize �✓ay'6ti r �-lam- _ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date - / o .asrlAuthorized Agent Fh,7rphyveclare�thatthe statements and Information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the d penalties of perju, Print Name kd e � Signature of gent Dat 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: I V-c U Ei Northampton I �? i i g Department 1 Main Street MAY 2 2 2001 om 100 Nor am ton, MA 01060 DEN OTFU1hiPToN W 0 587.1 40 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION tj 1.1 Property Address: , - ' � ° Lift DE SECTI ON 2 PR ?PERmY OWNERSHIRIAUTHORIZED AGENT 2.1 Owner of Record: ZZ Name(Print) Current Mailing Add ss: dL� ''✓ — � Telephone Signature 2.2 Authorized Ateen ;,a ,-� � T v Name Curre Mailing Address: �. ' Signatu Telephone SKs rrOr IESYrMAT D CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only 1'51-1t4pcompleted by ermit applicant 1. Bu' g , -7/< f e o (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) Check Number This Suction For Official Use Onl Building Per rn•it Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Data BP-2001-0958 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofin BUILDING PERMIT Permit# BP-2001-0958 Project# JS-2001-1722 Est.Cost: $8435.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Robert Thibodo 065699 Lot Size(sq.ft.): 161 17.20 Owner., KLOC STEPHEN S III&LISA J Zoning URB Applicant: Robert Thibodo AT. 87 HIGH ST Applicant Address: Phone: Insurance: P O Box 201 (413) 586-0391 NORTHAMPTONMA01061 ISSUED ON:51221010:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, SHINGLE & PLY ROOF 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 Signature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 5/22/010:00:00 7687 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo