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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building 'e
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Ii ccnsee�permi tt ere}
with a principal place of business/residence at:
(phone#)
(street/ci ty/sta&zi P)
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees woriang on this job:
(IIIS4 ance Company) (Policy Number) (Expiration Daze)
sole proprietor, general contractor or homeowner(circle one) and have hired
e ors listed below who have the following worker's compensation policies:
(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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach_111)b,oc2l sheet ifaaccuuy to ine}ude info mstoa pertaining to all one
a sole proprietor and have no one working for
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pawns to do maiatcaanor,eonsuucdoe or repair work an a.dvmlling of
not more than throe units in which the homeowner resides or ou the grounds appurtenant thercty arc not Cco rally ooandcrcd to be
employers under rho workces comp=4ca Act(GL152,ss 1(5)�application try a homeowner for a 60=0 a Permit may cvidcnoe the
legal status of as employer under the Worlds Compensation Act.
I understand that a copy of this statement may be forvmr ed to tho Dtputncol of Industrial Aocideats!Offioe of Insuranoo for the
oovcrage verification and that fade a to secure ooverwgo under section 25A of MGL 152 can lead to the imposition of criminal Penalties
comking of a fine of up to S1,500.00 andlor imprisoamend of up to one year and civil penalties in the form of a Stop Work order and a
firm 0(3100.00 a day against mc.
For dl use ash
Permit Number
Map# Lot#
Signature of Licenser/Permit#ee e
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
/� Not Applicable ❑
Name of License Holder : P /soG f ft v
License Number
Address Expiration Date
jf ���
Signature Telephone
.. 4 Not
s x �. . Applicable ❑
.:3:� Y..!E
__ ._ u _.
Company Na 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...... ❑
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
C 5- R PTl PnSE the k all.a l a le
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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-0WNER AUTHORIZATION .TO BE COMPLETED WHEN
OWNERS AGENT OR"CONTRACTOR'APPLIES FOR BUILDING PERMIT
I,
�P Y► P> /!/� �i P� as Owner of the subject property
hereby authorize ' f-/fG�' to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date.
I _r)61�_j S , as /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.
-
Print Name
Signature of Q, '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
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 w..
Qi Northampton
a B g Department
t 5 '2 Main Street
Room 100
m ton, MA 01060
DEPT 1
�ol�t-r.��►orte��1�'5 - 240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This sects ` t .b4 completed by offit
1.1 Property Address:
20 „ x0 1Cisticfi
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
C'-j elep one
Signature
2.2 Authorized Agent:
f , �, ^.4& c 177, i Al 66s -57— Ufa '
Name(Print) C rrent Mailing Address:
v ��`�T Telephone
hone P
SECTION 3-ESTIMATED CONSTRUCTION COST`S
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. Total =(1 + 2 + 3 +4+ 5) Check Number
This Section For Official Use Onl
Building Permit Number: gate Issued:
Signature:
Building Commissioner/Inspector of'Buildings Date
20 Fox FARMS RD BP-2001-0290
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 148 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofmg BUILDING PERMIT
Permit# BP-2001-0290
Project# JS-2001-0465
Est. Cost: $3327.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 14636.16 Owner: DUBE PIERRE W&MILDRED K
Zoning:URA Applicant. DE Sheppard Roofing
AT. 20 FOX FARMS RD
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON.9118100 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 9/18/00 0:00:00 2010 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo