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17A-184 (6) A (rii-�3 Of �,Tclrt11a111ptoil qli��xrf)ncrlla DEPARTNIE14T OP ©Utr-OrNG INSPECTIONS 212 Main Street A Municipal DuddinP Northampton, Mass. 01060 WORKER'S COi�'MENSA'nON MSUR"CE AFFTDANTY (I;cc-ns--cJPcrn»ttcc) %with a pancipal place of business/residence at: GL 65; S-7, (sacs-- City/stale./a do hereby certify, under tic pains and pen2lties of perjury, I1:11 ( ) I am an employer providin- dic following worker's colnocns<:,io:: cove.,-3--c for Inv c;roplovccs wor�jflg on this job. (Insu-raw Corr �) (P0liC- ?��airr) --- - (� :piruor, Date) v, ( ) I am z sole prooretor, general contractor o� homeowner (ci do on--) and have hired the contractors fisted below who (Lave the follow* 9- worker's comnensz'.ion pclicies: -._.---(Nnal 0. Con]-.-".'.Cio-) (Name of CO0[T--CiOf) -- (lnsuancc. ComnaawPol c- Nu-m cr) (-npu Lion Dztc) (Name of Conn-acio.) (Lasufanc Compan)•/Pot;c)• N.u)_b l) _ (-xpiF loo Daic) (i�'afnc of Coninc(or) (Lasurmcz Compaay/Pohcy Nuot>,r) (ExT, ration Datc) inrcK-Jnk:ioc p�ta:.ains to All am a sore proprietor and have no one work-jog for me. ( ) I am.a home owner performing all the ,vork myself. t4oTE--plcs-be c"'Lt"w I_)c H`oo c¢r,l ay p-zcax w 6a c' c l crX A d,,c -z of ant n:oce Q--c Q-rc.L--I?,,in„1,iC�ttx 1�.-rmaave-rtaidcs or oa the a-aa�s ipp�ztrci-r tbeen LT aV C._�.r-liv occa --cd to be --ploys-z und.:.LS:..0 l da cc:: ---lino k1(GL152-=1(5)�apptintioo try a 6o-,ncow-,,a fc;c U='-w:u rim rnzy c%id-D«trc Ic�l ctsau of cn crPfoyor uo',cr drn\-Vlka-, nd 1 "dc-"—d r-4A'a oogy or thu crskmcrit=AY bo f.,-a.,Jl d W tbo popertm ,or OT,—of(—Cot the covcnsc KYiflcLOa aid th t f_iJ rc to ccauc covcra�tmlct loci on 25A oI f•{OL 152 can lad to tl- i_a*0sitica of rimin,l pcasJbCa 000aiving a(•rioc of up to S I_�00.00 And/or cnpriaoouso or up to oex year cod civil p=,)-ao in tic form of a Stop Work Order end a Tiro o(Slt)D.00,a.y,FpinA(>r ------ ------ For dgxtnr-,i u.c only peruuf Number S atn of Li=sCCA)Crnultcc) e � ? V .,'SS- J'rt SECTION 8-GONSTRUCTION SERVIGES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder :T��!J ,o/Q 06 3,0 License Number 6/ Address Ad Ex iration Date P c 'L�1`a/70 Signature Telephone 9'Reeisteied Home improvemerif Contractor..-::; Not Applicable ❑ Company Name Registration Number Addr ss 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. Owl Signed Affidavit Attached Yes... ! No...... 12 11 Home Owner Exemption +r 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 v ""CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) 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❑ 6a'`'if New,hbuse'and or'addition to'diist ng housing complete the following: a. Use of building : One Family Two Family Other I 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 ellilk g. Energy Conservation Compliance. Mascheck Energy Comn. h�nce•form attached? 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 . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a- OWNER AUTHORIZATION -TO BE COMPLETED; WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT rr as Owner of the subject property hereby authorize r !loo �f , /� to act on my behalf, in I matters relative to ork author! ed by this building permit application. �- t 70V Signature of Wner Date 1 as Owner/Authorize A ent hereby declare th the st tements 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 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 Bid-. 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: p y ♦.`s r f Northamptont, of u Ong Department ��rr d rub �r � l,� �- „ �a..�' � ��� �, 1 Main Street werlSe try lib+f �� � oom 100 pEP�0� lost. pton, MA 01060 Two SetSiiuctural P ansJ M e -587.1240 Fax 413-587.1272 FotlS�tepians z .rvY other APPLICATION TO CONSTRUCT, 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 6�G,FV&f_ �~ Map Lot Uni# ” Zone Overlay District Elm St.District CB District SECTION`2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C rrnnl ''uiling Address: { Telephone ` Signature -� Z 2.2 Authorized Agent: Y&J�Q Apo t-! Name(Print) Current Mailing Address: 2-99"x'/2 ignature Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only com plete by ermit applicant 1. Building kF 0 f (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) l��5� Check Number d This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of-Buildings Date ,► y 181 NORTH MAPLE ST BP-2001-0130 GIS#: COMMONWEALTH OF MASSACHUSETTS rl*Ift:Block: 17A- 184 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2001-0130 Project# JS-2001-0195 Est.Cost: $1465.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor. License: Use Group: DE Sheppard Roofing 105885 Lot Size(sq.8.): 7187.40 Owner: SCHECHTER BARRY D&KATHLEEN L zoning URB Applicant: DE Sheppard Roofing AT. 181 NORTH MAPLE ST Applicant Address: Phone: Insurance: 17 1/2 Brigjzs (413) 529-0170 EASTHAMPTONMA01027 ISSUED ON:813100 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF OVER 1 LAYER 12 SQUARES POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Jnderground: 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 8/3/00 0:00:00 2095 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo