17A-159 (6) f
04T
D � T
41 � ��ibbaCh ttbtllb
of 'Nal-flIalliptoll
m DEPARTMENT OF 133UILDING INSPECTIONS
212 Main Street ' Municipal Building;
Northampton, Mass. 01060
NNrORI;ER'S COMPENSATION INSURANCE AFFIDAVIT
(Ii c�LSerJPcrmi ttcc)
rith a principal place of bus*nesslresidcnce at.
(phone;')
(&trc�t/city!staic;rip)---�--
do hereby certify, under the pains and penalties of penury that_
O I a n an employer providing the followinc, compensation coverage for my
employees working on this job:
(Insliras�c Company) --- (Pelic,� itL�itrr) - (F�piratfon Dale)
O I am a sole proprietor, general contractor or 1-ITleowner (circle one) and have hired
the contractors listed below who have the foiloW-in� workers compensation policies_
(Name of Contractor) (Insurance CoLnp3,i)-/'ol1c-r Nuintrr) (FxpirntionDate)
(Name of Contractor) (Insurance Compan},/Policv Number) (Expiration Date)
(Name of Contractor) (Insurance Companyll'olict Nuull Lr) (Expiration Date)
(Name of Contractor) (Insurance Comcany/Policv NumPrl) (Ea�iratio❑Date)
(euad additional s?acct if n,,c to indudc infocma:ioo F_crtnin-:rte to ell ox�a�:�: )
i
( X atn a sole proprietor and have no one :"orkirg for me.
O I am a home owner performing all the work
NOTE:plcsac be aware that vhilc hcxncowncr3 who c:TIoy repair wuck on u d\�ntLing of
cot more 111.!-n thrce uzutt m wtvclr the hat:r_.ntvcr rr3idc:3 c.-on tl r un ,z urt ni t2rsc o a r rxX(orally oomidurd to be
crnt,loyc3 unirr thhc workcfs o xr c utico 11 x(GL152,: t(5)),-ppl;mnoc by a hcttwowvcr roe a 6, a p it nLay cv den x the
Icg11"( U"of an employor under the Work",&cocnpc Lion Ad_
I uadenttnd that a copy of thin etat.cnmt aray bo forwnrrial to tho DctN,rt^>r of L dri,trial A0.zid"ltf OfEoo of Irnivanw for tho
oovcsago vaification and that faiiurc to:r_atrt covcrabro ux- scctiou 25A d MOL 152 can ic-d to the inspositicm of criminal pcnaliics
coasis:l ag of a fine of up to S 1,500.00 and/or iii sorcn 11 of up to crn-}iu nnl civ l perrattio in dr.form of a Stop Work Ord--and a
rino of S 100.00 i day iast mmc
For dg ut11 u—mty
L40 t
r � � PCTTmt 1'Ittmt�er
Si&nAturc of Liccnsec/Tcr iittcc {
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
� ����� � License Number
- - - - -
Address Expiration Date
Signature Telephone 1
e is"tereii`Homeylm`Y vement?Contractor ,. ,r:':, ,„ „P,,, ;' Not Applicable ❑
CompAy Name Registration umber
Address Expiration Date
Telephone l� 00
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...... ❑
M� � ''r
1 . _ ,omeOwnerrExempt�on
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 fe-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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ )) Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: �Vv' "1 � _ `F
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet o
6a.11f VdW1!K use.and or:<'addition`to"'existin7 housing complete the following:
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 Nc
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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _ _ __ to ac, or
my behalf, in all matters relative to 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.
Signed under the pains and penalties of perjury.
Print Name
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:
•-- __ — — -
i of Northampton Siatus of Permtt r �`
4 a2 u ing Department Curb CutlDtrvewa.
1 111 NOV 1 2 2C � �
12 Ma i n Street Sewer/Septic A aila'bls
Room 100 Water/Well Ava lamb i#y °'
L'EPTOf BLIILMIGINsPECTIOMortha pton, MA 01060 Two Sets oR' r C ural ands
1240 Fax 413-ID87-1272 Plot%Sete
Other Spec fy � {xr�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
} S � . Pllap Lot Unit
� f Zone Overlay Distract
c-
l 1 1 Elm St. District__ CB District —
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na ienr ) address:
r FpI',fl;•ie
Signature -- -- ----- —_----2.2-Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit a�)Qhcant
1. Building � — (a) Building Permit Fee —
2 Elec.rical (b) ;timated Total Cost of
Construction from 6
[-I Plumbing J 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:_ __ I Date Issued: -_ -- -
Signature: _ — — -- — ---
Building Commissioner/Inspector of Buildings Date
43 FOX FARMS RD BP-2003-0497
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map Block: 17A- 159 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003-0497
Project# JS-2003-0825
Est. Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License.
Use Group: HILLTOWN CONSTRUCTION 135036
Lot Size(sq. ft.): 27007.20 Owner: GRANT GERALD S&BERNICE B
Zoning:URA Applicant. HILLTOWN CONSTRUCTION
AT: 43 FOX FARMS RD
Applicant Address: Phone: Insurance:
P 0 BOX 514 (413) 268-0193
GOSHENMA01032 ISSUED ON.11114102 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:Q k /9.I 1-Q of
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/14/02 0:00:00 99 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo