17C-136 (5) 04 CttAMPTO
$ 6 �aaadlnactta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licsnsZrJpermittee)
with a principal place of usiness/residence at:
(phone#) °2 e7 �S
(strteUcity/staWzip)
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:
Once 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/PoGcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atfach additional shod ifn6o=mry to it vc u inf«muim per�to all o.traaors)
( ) 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 whilc homco-A co=who cmploy per-rc=to da m• arstructioa or rcpau work on a dwelling of
not mom than thtuo units in which the lwrmow-ncr rezidcj or oa the srvur,d,appurtenant thereto arc oot gcncally eoaridcrcd to be
employers under the worker's satica Act(GL152,ss 1(5)),applicztion by a homeowner for a licca:x or permit may evidence the
legal etntua of an ompioyer under the Works et CoMp,. ion AcL
I understand that a copy of this rratcmcnt may be forwarded to the Dcpw tr c of Lodushial Accidm&Of5oe of inau*noo for the
coveag verification and ttutt failure to secure covetngv undo sc-iioa 25A of MGL 152 can lead to the imposition of Criminal pcnalfies
oonlistiag of a fine'of up to S 1,500.00 and/or impris�of up to one year and civil prnalties in the form of a Stop Work OrdG and a
Em of S 100.00 a day tgniaA me--
For dcp=taxaW u,o catY
permit Number
r
Lot#
R:YY Sfgnatnrc bf Licrosedp ttee e i
a
��N i rRUc CroN sPyl 'S", t ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
tom, an am Registration Number
ddress / Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G:L c. 552, §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...... ❑
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
i z1 r A
S CTION =,D �R PO � c 1a lic b
CRIP
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing [!Y
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: x
Alteration of existing bedroom Yes Ad ing new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes Nc
Plans Attached Roll ❑- Sheet D
1f a �`eliti n o s in>�° =-in-g co �e Sf1 J
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 7aOVIINER AUTHORIZATION TO-;
BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES,E'OR BUILnING PERMIT
y as Owner of the subject property
IV
hereby authoriz to act on
my behalf, in all matters relative to work authorized by this building permit application.
9 sr�
Signature of Own Date
„' r.y�c. ✓ - n �' 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.
6
Print Name
Signature of Owner/Agent Date (i
i
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/Varian•ce/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:
a
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 e
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1-SITE INFORMA7`ION
1.1 Property Address:
EIm St btstrict s� $ �"`` ` �� ,•
SECTIOW2- PROPERTY OWNERSHIP/AUTHORIZED'gGENT
2.1 Owner of Record:
'&a. h R
Name Prnt) --1) Current Mailing-Address:
"' Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current ailing Address:
_ rJ
,rJ` ' i yr, 7 6 zy
Signature Telephone
SECTION 3 - ESTIMAT CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use°Only
completed by ermit applicant
1. Building _ � - (a) Building Permit Fee
2. Electrical n (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) I Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
'Building Commissioner/inspector of Buildings-." Date
66 NORTH MAPLE ST BP-2003-0458
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17C- 136 CITY OF NORTHAMPTON
Lot: -001
Permit: B u i I d i n�
Category BUILDING PERMIT
Permit# BP-2003-0458
Project# JS-2003-0780
Est. Cost: $14025.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq.ft.): 9626.76 Owner: FORSYTH ROBERT G&MARY W
Zoning:URB Applicant: Larry Paquette
AT. 66 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:1116102 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE OVER 1 LAYER 1/2 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 11/6/02 0:00:00 3166 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo