17A-078 0.�1vJfPT
�0
g E 11Tf-) of �\To f 11allip1011 �-
4 � E
Rla:3 _=
tnc h n ccl la'
o DEPARTMENT OP DUILDP�C INSPECTIONS _
212 Main Strcct ' Municipal Duildinl,
Northampton, Nfass. 01060
WORICER'S CO'MTENSATION LNSURA_NCF AI TMAM'
(litxuscc/pcnnittcc) ---- -
vAth a prLFIcipal place of business/residefce at
(sure tl6 ty/slatcln p)
do hereby terrify, under the pptns and penalties of perjury, .ha
(4C) I an an employer providing the following worker's colnoens::D0 , cove,,ye 'of Ind
eluployccs worlDng on ulis job
NIUMC 2-1
(Iasu =.(-- Cotar.y) (PoUc-. NtL-nirr) (r: irrio„ Dat )
( ) I am a sole proprietor, general contractor or homeow-oer (circle o:le) amd have hired
the contractors listed below who hzve the ioHo%VinQ Worker's policies:
(Nnivc of Co l�:-�!cto-) (lti_suranc: Colnoan)fPcuc Nu.mb_r)
(Name of Contractor) (Ii-s-Li aocc ComDa N,iPoticw Numcrr) (ExTU-Ziion Date)
(Name of Contractor) (In_surancc Comp2n)-/PoUcy Nnmbcr) (Expirboo Dale)
(Name of Contnctor) (Lasuran� Company/Pohcy Nmntrs) (Expuauon Datc)
(arlact3�d.i;;«:il c'_kC.if❑cc�ci.� to inc_�udv inforta.�oo patai.nins w.11 c«rrr_o�)
( ) I am a sole proprietor and have no one worling for me.
( ) I am a home owncr performing all tlae work myself.
NOTE.Plr_sc be ewarc Ole IU-0 bca3eowvcf�wbo employ pc Lo w do cr repair.,ork of
onl Mort ttvo tf:ro:tmmts in«;a ich the lwfnoowacr wide or cc the Qvuorr..�apputict.M the "not Gam"*=ally cot d! -�d w be
employe rvx c the-K� r1z or :t m ntt(GL12 31(5) anpbcn6cn by a hcmcowOa fcr c c _a perm t r=y c Aden«tl:e
Icga.l n,^r of nn c=;Iloyor uodcr din WOft'q-t Compoo,,-Li Acs-
[uodeni.tnd did a Dopy of thi.rt-.f—may tie roc--dnd to tbo popo.t--,r of lndaitriel Arad—&Offioo of lruu�fof tha
oov=gc vaif ralioo and t1Lr L1ltTC to tomm bovcfnsc tmdcr soulop 25 A of MOL 157 on la.d to tlx i=,ositioa of airmail pcoawcs
000iismg of a Uric ortW to S I}00.00 eodfot iM�i of up to one year and Civil Pauluc n tC form of n Stop Work Order Mad a
fim of 5100.00 t day tplazl me
ra dcp.fun--",t—Drily
Pool,Number
Lot
Signatu LicrsccPcrnittcc e�i /
s
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
^� License Number
Address Expiration date
,,— �, L,>1
Signat Telephone
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....... K 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
SCCT]ON S- DUCHIPT1914,OF Mf,OED MRK ObAck all applicabi
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing A„
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: Yi O�x.i--h VI fbCs �> mcO-�Ar)cd; rl�AC\ `�lT• Q`'�D�Aal A
—� )
Alteration of existing bedroom Yes No Adding new bedroom Yes No y1
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ Sheet❑ 41 CCJL.
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=`OWMER AUTHORIZATION -T&BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
!. as Owner of the subject property
hereby authorize I�ie+�C11�1 �'� t–i-'+`��v to act on
my half, in all ma ters relative tow rk authorized by this building permit application.
Signature of Owner ate
' as Owner/Authorized Agent
hereby eclare 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.
Pri t Name
/ r
D
Signature o wner/Agent to
V
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:
t
I!'^� � '��p .Gjy of Northampton
E 1�,.''' L5 U twil Department
ain Street
m 100
AUG 0,Aort ton, MA 01060
oE�tnfR ne 413 8 1 40 Fax 413-587-1272
vnntt+ VI ►NSP 90IiIS
APPLICATION TO , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-.SITE INFORMATION
r ' Th�s�seO i oe'omp�le ed b 'DEEM
1.1 Property Address: "` a r y '
/�
i lJlJi J'1...{1 1 1+° wi .y9�
t. _ rIr X
7— -- err /.l �r' F� sy aL j s
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam (Print) CLg t Mailing Ad e s:
l ` � t
Telephone
Sig tore
2.2 Authorized Agent: r�
Name(Print) Current Mailing Ad r ss:
Signatu Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS;
Item Estimated Cost(Dollars)to be Official.Use Only
completed by ermit applicant
1. Building Ll (a)Building Permit Fee
2. Electrical (b)Estimated Total Cast 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: ' Bate Issued:
Signature:
Building Commin slenertlnspector of Buildings Date
st BP-2002-0128
GIS#: COMMONWEALTH OF MASSACHUSETTS
.� CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0128
Project# JS-2002-0184
Est.Cost: $4400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Cyrus Newman 064690
Lot Size(sq. ft.): 9757.44 Owner. MALINOWSKI DOROTHY R
Zoning:URA Applicant. Cyrus Newman
AT. 30 CAROLYN ST
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:811101 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/1/010:00:00 2723 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo