05-022 0
Tit o a�tl��ilt�lfIItt L
� B �assaritnsttfs
�v DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
41ew
(licen�permittee)
with a principal place of business/residence at:
�/ / S �eJ °✓ . f`n �.� � (phone#)
(st rcWcity/statelap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy 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 Numbcr) (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 addihoml sheet if neoe:aary to include information pertaining to all coatrn m)
(�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 that whilo homeowners who employ persons to do maiaienaux,mastuctioa or repair work on a dvmUiag of
not morn than throe units in which the horuoowuer resides or on tho gems appttttenar4 thereto are not generally oonudatd to be
employers under the wod(eea compensation Act(GL152,vs 1(5)),application by a homcow=for a license or permit tmay evidence the
legal clatra of an employer under the Workee's Compemation Act
I underst a that a copy of this statement may be forwarded to the Dtpartmmt of Indrutrial Amdca&Offioc of Insurwca for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
oomisting of a fine of up to S1,500.00 and/or of up to one year and civil pemlt cs in the form of a Stop Work Order and a
fins of 5100.00 a day against tae.
For 6T=ttner3al use only
Permit Number
Lot#
Signabzre of LicenseefPermittee e
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ----
License Number
>ddress Expiration Date
Signature Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
Company Na� Registration Number
Address p 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...... ❑
11. - ,Home Owner Exemption
The current exemption for"homeowners" was extended to include Owner-occupied Dwelliny-s 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
SECTION 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 [ ]
3rief Description of Proposed Work: /c-e./ndue- b-'i+5}"v'T
Iteration of existing bedroom Yes No Adding new bedroom Yes No
attached Narrative Renovating unfinished basement Yes No
°fans Attached Roll '_, - Sheet
6a.if Newhouse and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
D. 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
li SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
I
Signature of Owner Date
e q , 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:
t y of Northampton t�f
lding Departments
z. �2 212 Main Streets 1
Room 100 �t! trfVeli� bt
tta`�P mpton, MA 01062 Tiro Sets of to r3Paans
13 587 1240 Fax 413-587-12
72 PlotifSite F'larfs
Other Specify_
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
,,Z�o CO �y(�yQU.✓ � Map Lot Unit
L Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I`
C'4A /bra s �
Name(Print) Current Mailing Address:
S'R/6
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Cur ent Mailing Address:
eo'_51�,- _�5,_e9 /4/-
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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
266 AUDUBON RD BP-2000-0809
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:05-022 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-0809
Project# JS-2000-1524
Est.Cost: $7800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Ed Corbett Jr 116069
Lot Size(sg. ft.): 51400.80 Owner: CANTARELLA HELENE P
Zoning:RR Applicant: Ed Corbett Jr
AT: 266 AUDUBON RD
Applicant Address: Phone: Insurance:
4 Reed Street (413) 586-5192
NORTHAMPTONMA01060 ISSUED ON.•3128100 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 3/28/00 0:00:00 3474 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo