17A-132 i
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
I L hone#
(strceVcity/statdzip)
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 working on this job:
•
(Insurance Company) (PoH7 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)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet ifnecessm y to include information pertaiaing to all 0003rectors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE-please be aware dw whilo homeowners who employ persans to do mamlca=cc,ebmtn=onor repair work on a dwelling of
not moco than throe unite in which the homeowner reside*or oa the grounds appurtenant thado arc mot grncrslly ooatidercd to be
employers under the vioricces;comp asation Art(GLI52,ss1(5)�application by a homeowner for a license a permit maY evidence the
legal status of an employer under the Workar's Compemation Act_
I undmund that a copy of this sutemmt may be foewnrded to the Dgmtmca2 of Iadu&isl Acci a&Office of lrrnusnoe for the
covmago veri&xiioa and tha failure to secure coverage under section 25A of MGL 152 as lad to tba imposition of timinal peaaltiea 1
oomistiug of a fine of up to S1,500.00 aad(or imprison of up to one year and civil penalties in the form of a Stap Work Order and a
fine of 5100.00 141Y sgninA me
For dcpatm4aw use only e
y
Permit Number
Lot#
' : of Li fire
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1
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Expiration Date
Telephone
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SEC1{ON10 3WQRKERS''CMPENSpTIQNSUE2N£ E AfIDAVIT(MG 1. c ;152,§,a25C(6}�3af
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,StatManLocal Zoning Laws and State of M husetts -eral Laws Annotated.
Homeowner Signature
1
f M
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: i C.e_e- • -k)a -- V&-e,) 2"y t e)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ ',Renovating unfinished basement Yes No
Plans Attached Roll o• 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
EW
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as Owner of the subject property
hereb authorize to act on
my heel alf, in all matters re tow thori d by this building permit application.
Si e. wner Date
1 , 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 perjury.
P". f Na e
'o wner/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:
j •
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, TWO FAMILY DWELLING
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1.3 Property Address:
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SECTION 2 PRO�FER7Y OWNERSHIP/AUTHORIZED AGIV f
2.1 Owner of Record: _
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Name(Pri ) C n n Addres : e�—
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Telephone
Sign re
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
ECr`frlQt �S• t 'A � STat�CTI=OST
Item Estimated Cost(Dollars)to befia1 use Only
completed by ermit applicant k,
1. Building / n Bu� gPermwr�
/ lx V K,
2. Electrical .
3. Plumbing Bildi� ertni# e
4. Mechanical (HVAC)
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5. Fire Protection
-te lie
6. Total =(1 + 2 + 3 +4 + 5)
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BP-2004-0017
GIS#: COMMONWEALTH OF MASSACHUSETTS
�`0k:17A-�14.° CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0017
Proiect# JS-2004-0027
Est. Cost: $12000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sg.ft.): 10715.76 Owner: TOBIN JAMES T&FLORENCE A
Zoning:URA Applicant: Larry Paquette
AT. 264 CHESTNUT ST
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375
EASTHAMPTONMA01027 ISSUED ON.713103 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. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Deuartment 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: Receipt No: Date Paid: Check No: Amount:
Building 7/3/03 0:00:00 3309 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo