17A-169 (2) 4�ttAMP�O
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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE t AVTT
I,
(li censee/permi tzee)
with a principal place of business/residence at:
(phonet#}
(street/city/staie/ap)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Lasu.rranee Company) (Policy Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,f
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Innlraace Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (E)cpiration Date)
(aUadl additi onal s+xct ifnccc=vry to include infurmi.'ioa pertaining to all o«itrncion)
4 I am a sole proprietor and have no one working for me.
O I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pczom to do ma ntnaa cc !Szr=on or repair work on a dwelling of
not mode than thmo unit,is which the hoa»owncr raid,=or on th,c g<ourxis appurtenarrt thado arc ry-t Ecocrally coaridacd to be
employers under the warmer's a=mpensatica Act(GL152,--zs 1(5)�application by a homcouvcr for a Lccose a permit may cvidcnoe the
legal etatue of an employor under tho Workcer,Compamatiou ACL
I uadcrrtaad thrt a copy of thin rrat=zcd may be forwarded to tho Dcp<vtmcaf of Indzrsfriai Accideats'Offroo of lz�for tho
coverage vcril'cation and that failure to&earn covttago under sectioa 25A of MGL 152 can lead to the imposition of criminal pen&W(es
oomisting of a rule of up to S 1,500.00 and/or impris�of up to one year and civil pcmltia in dc form of a Stop W on Onda and a
find of 5100.00 a day ippinsl mr-
For&p—ft—al—only
• � ``O� Permit Number
t Map# Lot#
. Signature of Licenser/permittee e
( v
SECT�bN 8 CONSTRUCTI0 ;SERVICES
8.1 Licensed Construction ervisor: Not Applicable (❑
Name of License Holder
License Number
KK (Cr- a4- 0 3
Address Expiration Date
Q -to-J�-
y�3 Sg 03 a�
Signature Telephone
Not Applicable ❑
Company N I Registra ion Number
is? Qk1b#N a so
Address Expiration Date
Telephone4il L S o3aO
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 affida
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)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 _
X3,3.3.
SECTION; DESCRIPTIONOF3PROPOSEDINOR ffieckall a livable
�•.fi9�,x �3r.«�� i�x,v`%aR.;.hS A>>r.P£,rT3�Y x ,hll3r>» „4 133p\ . �aai.�.�, aF
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 bedro m Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet o
s f Neriv house Iii o° chit°on.,to ez�stin° housin com I"ete�Yie fol1,o, "
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
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 `:OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS.AGENT OWCONTRACT,OR APPLIkS F6kz,BUILDING.PERMIT
•
1. ' It &Wks Owner of the subject proper
hereby authorize �� �� Qd to act
my behalf, in all matters relati�v�o work authorized by this building permit application.
Signature of Owner Date
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.
Signedl�r-the amend nalties 6
Pr i Name
"1- ,-
O �
Signature of 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
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:
ONNNOWNEMW
t
City of Northampton
Building Department
212 Main Street
Room 100 to;14
Northampton, MA 01060et a
a
phone 413.587.1240 Fax 413-587-1272 Plot%Site .
3
Ot e�i
at,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section t k,completed by*off>lCe
1.1 Pro ert Address: +
t" -
Map L t �
AIN9'
ZoneOverlaysbistrlct
Elm St. District CB District
SECTION 2- PROPERTY OWNERS HIP/AUTHORIZEDiAGENT
2.1 Owner of Record:
Sa s 0 Ao ItS Name(Print) A vim% C. Q �'Y' Current Mailing Address:
z A '
�. J Telephone
Signature —
2.2 A thQori ed A enI
oNe
Nam�t) Current Mailing Address: 401 Wei
'KI C770� o3 "I" 1
Signature Telephone
SECTION'3 - ESTIMATED CONSTRUCTION COSTS y 64 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 Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2003-0037
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0037
Project# JS-2003.0102
Est.Cost: $4285.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT D THIBODO 118441
Lot Size(sa.ft.): 8537.76 Owner: DRESLINSKI STAN&
Zoning:URB Applicant: ROBERT D THIBODO
AT. 16 HOWES ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-8966
NORTHAMPTON MAO 1061 ISSUED ON:7110102 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 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 7/10/02 0:00:00 1161 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo