11C-032 Y
The Contntonwealth of fassacituserrs
_ � =�- �eoarrmenr of L�tdusr;-iar_4ecidents
=
- O,jace oflnvest.`arions
=.7-
600 if ashing ton Street
Boston, ?4IA 02111
>ti—wnwnass.;ov/dia
«'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians,'Plurr:bers
AnaIicant Information Please Print Leaibh
Name Business/Oroani:ation;'Individuali:
_Addr-.ss:
Citv'State/Zip: Phone T:
Are you an employer' Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.❑ I am a employer with ❑ 6. New construction �
employees (full ana or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner_ listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in an employees and have workers'
Y capacity. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required-,
�. ❑ We are a corporation and its 10.❑Electrical repairs or additions
:.❑ I am a homeowner doing all work officer have exercised their 11.❑Plumbing repairs or additions
myself. [-No workers' comp. right of exemption per_MGL 12.7 Roof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.7 Other
comp. insurance required.]
`Any applicant that checks box=i must also 511 out the section below showing their workers'compensanon policy information.
T Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractors must submit a new affidavit indicanna such.
=Contractors that check this box must attached an additional sheet showin.2 the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providin.workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy�_or Self-ins. Lic. ;r: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
c'up to 52:0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby cerrifi under thepains and penalties ofperjury that the information provided above is true and correct.
Signature
Date:
Phone =:
'Jfficial use only. Do not write in this area, to be completed by city or town ojTiciaL
City or Town: Permit/License r
Issuing Authority(circle one):
1.Board of Health 2.Building Deoartment 3. CirviTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
j Contact Person: Phone
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.31.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation/footings (before backfill).
sonotube holes (before your). a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, L�� understand the above.
(Home own /resi ent's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date ?--aLs —ap6
Address of work
location
• ,,,°t• 3'F.e Cotten-er.N�eelth ofX==j rs=
37c,�s:r�srrr_•�of3Kdmg.u'dAcddrnts
Of'sed oflr_tesu'gc�olts
� G 600 FP'4tF,iVran Soars
' ,$osun,�lfA 02773
'C~ wwrw,rr=COVACO
workm-S, Cempeasation b m a�cc AjEdav'it 73a7ders/Coatraecorsl le 2se p1dat hers
a.c lice t 1'ufors'.►,sation Please Print LeNbI.
• � lie rr'�-ra,[z.,,, �: '— �•�wf�. 0�r�t.le./_
wale(Ausencs�/On�salaa'oa'ladivldcraJ). ��"T"
:4dcress: 10 3 the ro,n 5fi
Citv.'Stau'Zi Phone
Are y oa as emplaYce Cbedt:the agpropriase bor Y'ppe ofprojcct(regNred):
I.C]I a coloyc with 4•�amu Smw'conrint: r=d Y 6• ❑mew etnL�MiLtioo .
=ploy=(full and�or past-t5:at:).� bave batd Me=b-eout2xsom y. R=oddimg wads--'S
Z.❑ r a:>s.a sole prI*dC o:or p=ct- lLazed ao the anrbcd sbc=e.
e sub-co^,.,r•.=bar a. ❑Devaclidom
sbp and 2�ave oa e ]o to art!lave wot=s'
WorkiaS fa:raa b aay c=padty. = Y=om 9. ❑gtst7diag additsca
cotes.icuuaac=;
o �rluss'eosap. aea S. We are a ca:pors$nn and its. 10.[��Ie�sal sepai�oc adtiltiat7s
afrcxss bsve e Clsedtbeir IL[2 Pl=bng ztp�c adadons
3.Q F aa a h cwAmcr doinr LU we-- �of r j
daa pcc.MU- LLCYR aaf.
nocM CC w�'cam• e.LV,51(4),rsd-we havcno Od7c
]T CMloY =(No vnnlctss' ]3.Q
Cosm
P.iz>rtasace r..qucd.] '
" appUr:ortds�cde-Jc,bnx�1'»us�> eanauftctccdaabrta-lta�la9dryw coctper3sie0frolic:►lnsbtnaaan.
THomo wmc Twhosu ht,'cdth *ark oadCumbinoao+de �p�;aaer.rl��ctbdleadnaspeh.
%Conaaesoes dot eheelcdtts Lax�ra�ehed an adddanal lih�s ebp+�p�tbeaxale of ttx wtt�aCata?G stud tsatt w6esbcoraott§ose saes tam
cagio.ea Irthrs is h:+c aaplord.dur mm pV,rJda glek wml=r=,.patup aumbe.
• I airy 4n employer that it provlfrr worL•ers,Corhp oft txxtrrm':teJer rrgr emp/oyccs: �Icro drQpoFicy and f ob slt�
iRformasioR. t 1 L� f(A OL
lrtsurina t:aaspany Nax �ssoc�G ;°(,A , n kus�r i iS Q
Paley N or Self-n..Isc.� A WC-70 5w 305 003 • a o
Tob Sit:,% s Cst)r�5tstr12sA:
A.=ch a copy oftehcWCrkeM7 cocgprj=Lioa policy dWjmr ieoa pa:e(shaw+iMg r$epoticpnv:cber acid exp1mlots dat:t:).
Fas7t>re to St=c eoo=ge= d mdcr Sew 25:t o f MGL r.253=]end to tllc impOaia0U of ai-ainaI Pcczltles of s
Scae up to$1,500.00 and/or aac ycaritaptcisa-m= as vrdl as eivll pcz: in thct'azraof a STOP WORX ORDIrRaad a fImc
of up to 5250.04 a clay agdasr tha vialAmr. Eo a6pised that a copy of tbb S'm=mcz[suety 1r-rmwrre'sd to tba Offiec of
Lsvesdgado=of the DIA for ktturaace coverast;va:WC2d;Z.
I do hereby eerafy u ,4t ,-pacts andp eft al ofperjttty srsdt the brfo rm C oar provided above is trcce and correrL
9.1f 4�3v-
-�• ,5' I&ig- --G6-C-3�
00c al avc o.rbr. -Do nai wrkz G llrtc area:w be eoarpleed by r1ry or tofua o,jgiccL .
Ci*,or Town: Pcrml!lLiceau R
•� Isauieg Authority(circle one):
].So=d cfzrwtb 2.3cDdIng Acpar=cat. S.-G,v,7o±va ticrk S.£lccfricsi Yaspeetor S.2luazbl>rg Iaspe:tot" .
b.Othor •
Co pLti cr Parson: Pbaee R: '
CD
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CL
Board of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement-Contractor Registration
Repi5tration: 154007
Type: NOW Corporation
Expiration: 11312M Tr# 25060
ED HERRINGTON INC
FREDERICK HICKMAN
312 WHITE HILL LANE
HILLSDALE, NY 't2629
Update Address and return carat Mark rtason for chwge.
cis cu a�an�asrt��ca�w E] Address []Renewol [ EmpIoyment Lost Card
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WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Industries of Massachusetts Mutual Insurance Company
Burlington.Massachusetts NCCI NO 2131158(800)876.2765
POLICY NO. ti2pnr I
ITEM PRIOR N0. I AWC 7010543012000
1. Thu Irc:urod Ed I Icrrlticllon Inc
Milling Addruus: P 0 Box 709 Hlllydile NY 12578
INC. Sheet In%nnrrlty Cnunty Moir zinCode
Indivirbial ❑ Pnrin(sr.nhlp M Corporalton ❑ Olhmr FEIN oli-o3n15'10
Other workplaces not shown above:
2. The policy perlod Is from1 110112 0 0T to 11/012008 12:01 a.m.standard thne at the insured's malling address.
3 A. Workers Compmnation tnsuranom: Fan One of the policy applies to the Wnrkers Compensatlon l.aw of the:.mmtes ifsimd here,
MA
B. Employers Liability Insurance: Pan Two of tlx:pollcy applies to work In each stato listed In(loin S.A.
The limils of our liability under Pert Two air:: Bodily Injury by Accldunt$ 500-M) each accident
13odilylnlurybyDl,tuttsu $ 500,000 pollcyllrtUl
Bodily Injury byUlucuaa $ 50n,Onn 0zclicntployee
C. Olhor Slates Insurance:Covnragm Rmpkicmd By Endorsmmnt WC 20 03 00A
U 'I his policy Includes these cnd0rse111erdl acrd scl'wdulc:j: SEE SCHEOULL-
4. i'hc pruntiutn lot otls policy will tic duluirrilned by our Manuals of Ruln-.: Cla�slfh:diur»,Rain;and Rullny plaits.
All information rcquirod h0ow is SubjuCI 10 uerltkxrbun rind change by audit.
Clats01calluns Ptuntfunt Bull; R:IIu::
[Lunt ad Pm$100 Cclinialed
roe" Inlnl Annnnt ra Annuat
No. Nemiinrxahnn Nrm�nnrnluin
F1reuum
INTRA 422753
SEE FXT .NSION OF INFORI JATION PAGE
Minlrnurli prumiurn$ 1138.00 tali Eslitruitud Annual Premium $ 1,130.00
As Indirmled,interim adjustments:of premium shall be made: Deposit Premium S 1,171,110
❑ Annrinlly ❑ Serni Annually ❑ t'Juanerly ❑ Monthly
MA Auatr wrtenl Cltg.
S63r.45 a S.SW01% 535.00
1�0 OJ2'll'1UU7
Thin policy,InGi.idlno all onrinraements,is ttCrrby cauitirrsigitcd by �___.
Autimized SlWraluto Dale
GeV Gov KING CLAIM NAME SAFETY
STATE CI11-SS AL3DIT 01=FILE OFFICF. CHECK CROUP 1.V'I vale Invuvince agency
MA 10606 2 0`02 195 Niant Street
WC 00 00 01 A(11-88) Lee,MA 01213
InrModr.z rnrynOMrQ mntrnnl nt the wirnnnl I:r mil nn I:n ,mutt~Nw rt]iY,.
4)9(1+IIII itu ppmiLLkff'.
SECTION 8-CONSTRUCTION$ERVICES.
E.1 Licensed Construction Suaervisor, Not Appiicable ❑
i
Name of License Holder:
license Number
Address Expiratlon Date
Signature Telephone
A sle: :0i . 11Fiaavra ' 4,a ��1 ,` Not Applicable ❑ .
J
C9m02nv blame Registration Number
Its, t � c-5 1?1q900
Address Expiration Date
/d 3 day yvi �r W S .�nc� � 0l�zs`1 Telephone
SEC11 ON 1:0-WORKERS!C.OMP.-.Eb1Sp:.T1 G(6�
Workers Compensation Insurance affidavit must to completes and submitted with this application. Failure to provide this afftdavit yyill rasutt
n the denial of the issuance of the building permit.-
Signed Affidavit Attached Yes....... 0 No...,.. 11
The curreuT exeMption for"homeowners"was extended to include Owner-occupied weilinss of one(1) or two(2)families.
and to allow sue t homeowner to engage an individual for hire who does not possess a license, provided Wt the owner acts
as supervisor.CMR 780. Siith Ectitio Section 1083.5.,1.
Definition of Homeowner;Person(s)who own a parcel of land on which he!she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
saitcttues.A pzg'm_qjq who con ets mot than one home in a two-year a 'od shall notbe c nsidered'a ttoA0leowA r:
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.-that he/sbe shall be
responsible for all such work performed under the buildinz permit.
As acting Const"ctioaa Supeivbgr your presence on the job site will be required from time to time,during and upon
completion of the work for which this perrnit is issued.
Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be_lia$le for persons)
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.
f Homeowner Signature
The Commonweatth qfMassdah.u5ctz's
D ep a rrm ex! of in du 5rria I A c ciden rs'
0J'J12Ce of Irrvestig"ariom
600 Washin-ton Street
Boston,M4 02111
ass.govlldia
'Y'Vorkers' Compensation Insurai.3ceAffidavit: Builders/Contractors/Electriciaias/Plui;Abers
Appliunt Information Please Print LedbJv
'ante(Business/Organiza:joriqndividual):
Address: /0 0/0 3q
city,/Stale/zip.- Phone 4.
Are y-ou an employer?Check the appropriate box- Type of project (required):
I.0 I am a e'niployer with 4. �Rq am a general.contractor azd 1 6. 0 New construction
c=loyccs!full and/or part-time)-* have hized the sub-contractor
listed on the attached sheet. 7. 0 Remodeling Wwth'�-
a. g.
P
}nave d ac
on
d 1 6-Y
r
a 0 n� Or aii pro
Newc
project (re
ons�
s t 7 Remodeling rn
2.0 1 am a sole proprietor or partner- listed n�'attached �C' R�01.uou'
ship and have no employe=s These sub-contractors have 8. Demolition
'r rs
d have c 9 -1 g addi
ernployces and have workers BW
I rep,
working for me in any capacity. 9. E]Building addition
comp, insiarancc.-
No workers' comp. insurance my M
F-1 We are 2 corporation and Its 10.0 F-lectri.cal repairs or additions
requixed,j corporation an
fficcrs have exercised their
3 or 11.0 Plumbing repairs or additions
❑ I am a hux:aeo-;;t-acr doing all-work-
right of exemption per,MG jL 17 D myself. [-No workers' comp- c.- , §1(4),and we have no Roof repair s
insurance required.] 152
employees. (No workers' 1317 Other
comp. insurance required.]
*Any applicant:hat checks boat#1 must also,1U out the section below Showing d-.eir workers'compensation Policy inforTrwicn.
Umeo-nen who subtw'r this a2fidav4rir)6,-'c2d,-g they a=-doing Z work acrd them bite outoidr eon==Ts r=t subrriT a new affidavit thdic2ting such.
*Contm Mm that check this box must attached an additional sheet showing the name:of the sub-cana=turs and state whc her or not those entities have
etrptoyees. Ii the Sub-cont-acton have employe,they must provide their workers'coup policy number,
ram an
employer that is providing workers compensation insurance for my employees". Below is thepozecy and job site
Mformation.
Insurance Company Name.
Policy'r,or Self-ins,Lie.t: Expiration Date:
Job Site Address: City,State/Zip:
Attach a copy of the VVorkers, compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c, 152 can lead to the imposition of criniiiial penalties of a
fine Lip to S1.500.00 and/or one-year imprisonment, as well as civil perialtiC5 in the form of a STOP WORK ORDER and a fine
of up to 5250.00 d day against the violator. Be advised that A copy of this statement may be forwarded tb the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby Ce;,dfyunder the pains and penalties of perjury that the Mformationprovided above is trice and correct
5j Date;
61-61 0-3, tze -0/97
r5 I/-��) ---(,:�/t 5� Y 3-,-
Official use OnZv. Do,not writ-o to thiv area,to he completed by city or town official
City or Town: Permit/License-r"-
Issuing Authority(circle one)-
I-Board of Healtb 2-Building Department 3. Ci-,,"Iowa Clerk 4.Electrical Inspector S. Pliumbing r c
Inspeto
Ispe to
6. Other
Cont_ictFer50n- Phone 4•
_
SECTION 8 -CONSTRUCTION SERVICES
B-1 Licensed Constructior Suoe^/isor: Not Applicable ❑
i
I Name of License Holder:
iLicense Number
Address Expiration Date
Signature Telephone
R�eciistered Horne Improvement Contractor: Not Applicable ❑
COmoany 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...... ❑
I1:= Hame Qwner Egerimpti6n
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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 fans
structures. A person who constructs more than one home in a two-vear 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 buildinZ 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.
JHomeowner Signature 4�7k�
S=CTiON 5 DESCRIPTION OF PROPOSED WORK{check, all aoolicabie�
New House Addition Replacement windows Alteration(s) E-1 Roofing
Or Doors i&.
II--11 i
Accessory Bldg. t_ Demolition ❑ New Signs [p] Decks [[1 Siding[Gl Other j0]
Brief Descri tion cf Proposed
VVcrk: �NQX3 3 i_o"'\&(3 W% -N 1 �G��-n (�OOr
Alteration of existing bedroom Yes_�No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
Ga.-if New house and or addition to existing housina complete the 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. Masscheck 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
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-70:BE COMPLETED.-.WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. 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 penury.
Print N-me
00
Signature cf Owner/AO .t Date
` .
| �
Sec^'o ' � D~'�'G ALI ifformation Must Be Completed. Permit Car,Be Denied Due Tc Incomplete Informa=11
Exi'st"na ProDosed Required by Zoning
This coiumn to be L'illed in by
Building Depamnent
rLo,Size
L07,5 Z-7—
pFronta:2e
Setbacks Front
Rear
Building Height
Bldi Square Footage OX0
ace Footage 0%
Pen
r,(L.,,=Sapminus bldg&paved
#of Parking Spaces
A. Has aSpeciaiPermit/Yariance/Finding ever been issued for/on the site?
~\� y~�
NO ��/ DDN7KNOY� \�� YES ��/
�
IF YES, date issued:-
IF YES: Was the permit recorded at the Registry ufDeeds?
NO ~�� ) DONTKNOYY 0 YE]
_ __-0�-� _
!F YES: enter Book Page. and/or Document#� ,
B. Does the �p contain a brook, body of water oretiands7 NO t�`
site DONT KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission? '
---------r�-
Needs tobeobtaned �-\ Obtained /~� Date x~~/ ' '
C. Do any signs exist on the property? ��y� 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 0 NO yk
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading vation, or filling)over I acre or|sit part ofacommonplan
that will disturb over 1acre? YES � ) NO f�J
�� v�
IF YES,then a'Nort6�m--�-tbn86��'00�������gehent-Pennit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Ri,.i;l.rfi..n,n� Depeirtment. Curb Cut/Drivew ay ay Permit
212 Main Street Sewer/SepticAvaitabiIity
- Room 100 Water/ttVellAvailability
Northampton, Mr. 01060 Two Sets of Structural Plans
is a 2 ;�.pt �$ 413- 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICA T ION TO LbM T RUC ',ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
i
\,eS Zone Overlay District
Elm St.District CB District
SECTION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
poro .�"�.i -�o
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorize A ent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION:COSTS I
I Item I Estimated Cost(Dollars)to be Official Use Only'
completed by permit aoolicant
1. Building �� CJ� I (a)Buiiding'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) �,rjz{\ �jo �! Check Number
This Section For Official Use Only
-Date
Building Permit Number Issued:
Signature:
-- -----Building;Gemmfssione�/lospe�to�ot: wamgs Date
BP-2009-0325
GIs#: COMMONWEALTH OF MASSACHUSETTS
mmmmioavaivw-�",` CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0325
Project# JS-2009-000446
Est.Cost: $4542.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ED HERRINGTON INC 154007
Lot Size(sg.ft.): 13416.48 Owner: ELLIOTT DOROTHY L
Zoning:URA Applicant: ELLIOTT DOROTHY L
AT. 9 STOWELL ST
Applicant Address: Phone: Insurance:
WC
LEEDSMA01053 ISSUED ON:912412008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 3 REPLACEMENT WINDOWS &
SCREEN DOOR
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:
FeeType: Date Paid: Amount:
Building 9/24/2008 0:00:00 $35.002949
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo