17C-137 (2) ` 4.�ttAMp�O
0 a
9 �Z xrf 'Wart4alilpton Y
B B j�lassacflnsctts'
C
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFTTDAVIT
(licensee/permitter)
with a principal place of business/residence at:
? �V(,176'1,�. 1 C `2-7 (phone#)
(streeticity/state/ap)
do hereby certify, under the pains and penalties of peoury, 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/Poky 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)
(Acura additional shoe ifnw,=sry to in�informsiion pertaining to av ooemctorj)
�a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware taxi while homcowvcrs who employ perrom to do mxmieaance =,st-u=oa or repair wvrir on a dwelling of
not more than three umts in wlrich the l omtomcr r c=dcs a oa the grounds eppurue tha cto arc not ccocrany oowidacd to be
employers under the worker's.mmpcmaiion Act(GL152-"1(5)),applicatioa by a homcoww for a Game cc permit may cvidcace the
legal rtsdua of an employer under the Workor's Gomp*maiion AcL
I undereAnd thxt a copy of this rt&t=cat may be forwarded to the Doparwiocd of Indxutb ial Accida&Office of Iasun for the
coveng wrificaiioa and that failure to azure covaago tinder soctioa 25A of MGL 152 can lead to the imposition of criminal penalises
oomisiiag of a fine of up to S 1,500.00 and/or imprisonnxrrl of up to one year and civil pcnxtlics in the form of a Stop Work Order and a
fum of S 100.00 a day against mx
For&P-t� uao only
r ° Number
Permit Num
l ` Lot#
Signature of Li ermittee e
t
1 15
E }10N BCONS,TRUCTION SER1/ICfS
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
— � -�'
amt A ZC
Signature Telephone
Not Applicable ❑
e m f vemen•R.. n r` PP
Compan Name Registration Nu ber
Address
1 fxpirat not Date
Telephone J";2
jS 5- "Jo..WdRKERS'.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 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
EGTION �D R ��O PROPOSED�W��R e lea 'lic�abte �
14 ', R46 N
New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: � � �-'' �� �- `� "� /k 1-*&ZI 65f 7'
d
Alteration of existing bedroom Yes No Adding new bedroom Yes No '�'
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
a>ition-ato° exis_flfK" ho- spin c�eer �ful,l.ow;rn
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
L Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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
S CTIOI� . BE OMPl =T=D WHEN T�OR(ZATION Tfl Cel OWNER A1
;p NERS TOP"APPLIES �'OR U�LIING PERN�I�`
S
3
as Owner of the subject propert
hereby authorize _- to act
my behalf, in all matters relative to work authorized by this building permit application.
_
Signature of Owner Date
I,
L.Y
e-, a?-Ovmer/Authorized Agent
hereby declare that the s.`tements 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.
a M 11
Pri t Name f
Signature owwmer/Agent Date
• c
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:
Northampton
E � E V 2u Department
Main Street
om 100
JUN 18 200Ror ton, MA 01060
phone 413- 87-1 40 Fax 413-587-1272 ° :e
IN
Tect
DEPT OF BUILDING INSPECTIONS { 5n
ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE'1NFORMATION
his section,#o bye completed by office
1.1 Property Address:
Map Lot `a Ura�t
PVT
0 erIyDistrict e
a
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: —
�� Telephone
Signature
2.2 Authorized Agent:
2.1
Name(Print) Current Mailing Address:
G
Signature Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
co feted by ermit applicant
1. Building z _ (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 Section'For Official Use Only'
Building Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of B;uiltlings Date,;
r 'jqQRTftI l Sr BP-2001-1066
GIs#: COMMONWEALTH OF MASSACHUSETTS
'1C 137 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate o :roofing BUILDING PERMIT
Permit# BP-2001-1066
Project# JS-2001-1887
Est.Cost: $1235.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GrouQ DE Sheppard Roofing 105885
Lot Size(sg.ft.): 1 1 151 .36 Owner. HODGES RONALD F&LOUISE E
Zoning.URB Applicant: DE Sheppard Roofing
AT. 60 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:6119101 0:00:00
TO PERFORM THE FOLLOWING WORK.-FRONT PORCH 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 Type: Receipt No: Date Paid: Check No: Amount:
Building 6/19/010:00:00 2223 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo