17A-182 4�t1AMP��
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9 B Alsaachttrals'
e
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
W 0 RKE,R' COMPENSA ONCE Al MA AVIT
with a principal place of business/res' ence
hone#) '7—Z—V 77�
( city/ 22P)
do hereby certify, under the pains and penalties of pcqury, 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/Policy Number) (Expiration Date)
t.
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (HxT� ration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioaal sheet iFncccz�ry to inc}ucic informiIIoa pertainiug to all o�afrndota)
r sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcssc be aware that wILilc homco-Ancn who employ p=oar to do mxini� ', 7aa oa or repair work on a dwelling of
not ancc than three units in"inch the hottiooavcr raider or oo tho pnuadi zppurtcnant thudo arc no(gcnrrnlly oocndcrcd to be
cnyloycrs undo the worker's ccx�tion Act(GL152,sa l(5)),applim6on by a homco%-=fox a U—sc o<Permit may evidence the
legal aat a of an employor under tho Woukoet Cornpo=Atioa AcL
I undcnlwd that a copy of this rtntcmmt may bo forwarded to tho Dcpa�of In&iiti ]Ao6d=&Ofrioo of Inausnco for thn
eovcrxgc verification and that failure to—=covctngo under soaioa 25A of MOL 152 can Icad to the in:posiTion of criminal pcnalbcs
000sisting of a free of up to S1,500.00 and/or imprisonn�t of uP to one ytw acid civil pcnnitia ins-form of a stop Won Onia and a
fum of:S 100.00 a day aghast mw
For dq-tr�—oaly
Permit Number
��)� Map4 Lot#
Si tine of LiccnsscdPermittce e
SECTION 8 }�ONSTRUGTION-SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
--- �6J0 f"'?Name of License Holder :
License Number
Address Expiration D e
Signature Telephone
Wl
f t
Not Applicable ❑
Company ffarne Registration Number
zz
ddress Expiration Date
Telephon %G
SECTION 1 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, § 25'C(6)),
Workers Compensation Insurance affidavit m st be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of e building permit.
Signed Affidavit Attached Yes....... V 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 ��'+
M
SECTION DSCR PTIONOF PROPOSED*OR , c eck.all a tcablea�
t:.zJ313 .,in..._'.yS ,rll)W;:'.� �;,_'i 3 5MM?. ce „.,n,tl '' .,,v -d:, tl.,en.»" ,1s11?YaF` k6YtQ..tl3.H3fl ., Irl3, m�,1�7N .d �,:!•.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: ►e
Alteration of existing bedroom Yes No Adding new be room es No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet❑
6' IMe o se. nd or.: ddition to ;eit�stii tiousih coMlfb a-,li"e foClowi i
a. Use of building : One Family Two Family !:O�_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
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 OWNERaAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR.CONTRACTOR APPLIES-FOR BUILDING PERMIT
as Owner of the subject proper
hereby authorize o b£ '(— �Jl b 0 Ci to act
my behalf, in all matters relative to work authorized by this building permit application.
JtA�
n
Signature of Owner Date
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 thL..pains and penalties
Print Name
c
Signature. Owner/Agent Date
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
s 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:
�n Northampton
E C E � ll E B I i g Department
In Main Street
AUG 2 4 2001 oom 100
No pton, MA 01060 s
_phone 413 587-1240 Fax 413-587-1272 PatSte
EN
DEPT OF BUILDING INSPECTIONS
_
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
sTh+s sect+on#o b ompletedby of�+ce
1.1 Property Address: �
"'M
, h
Map Lath UrSrt R
x
s
Zone �� Overta}rb+str+c#
Elm St District CB District!
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reco d:
N
66 z
ame(Print) Current M ess:
R W —ro 1.l L S Telephone �7
Signature V p
2.2 Authorized Agent:
6X7- 1_1711&04J i
Name Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION'COSTS o-
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (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. Tota! = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2002-0212
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0212
Project# JS-2002-0334
Est.Cost: $7835.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sa.ft.): 718 7.40 Owner: TOWLES JEAN M&EDWARD A SR&
Zoning.URB Applicant: Robert Thibodo
AT: 187 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMAO1061 ISSUED ON:8124101 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/24/010:00:00 7663 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo