17A-252 (3) ��ttAA1P�O
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DEPARTMENT OF EUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORCEITS COMPENSATION INSURANCE AFIt'D7AVIT
(licenser�permiuee}
with a principal place of business/residence at:
-- (phonef#)
(str eet/city/state/zip)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on tliis job:
(Insurance Company) (Policy Number) (E-piration Dale)
. j I = a sole proprietor, general contractor r homeowner ( 'rcle one) and have hired
the contractors listed below who have the foll o� s cornpensadon pohcies,
-(Name of Contractor .ration Date
(N ) (Insurance Co>xlpauy/Policy Number) (Exp' )
(Name of Contactor) (Insurance Company/Poky Numb--r) (Eafpiradon Date)
(Name of Contractor) Gmsuranc�t Company/Policy Nurnh�-r) (Ex-piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach a61itioail shed if nccc ,,to ixludc iafocfnitioa pertaining to all o�a'tndors)
O I ann 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"41ilo homcowvaa who employ pc�iou to dJ c a n c tub cc, u—oa cr repair work on a dwelling of
not more than three units in Airdi the homeouvcr resides oc on the gouad} zpputtentni thadD arc oo(Ecncrnlly coasidacd to be
employers under the wocittt's a^rr4xnsatioa Art(GL152,ss 1(5)1,application by a homeowner far a liccrsse cc pclm may cvidcnoc the
legsd clatu of an employer under the Workeet Compoosatioa AcL
I undcrrzand th:t a oopy of this axtcmcat may bo forwarded to the Dcpaftmct d of Industrial Acc dcnt-e Offioo of Insausnoo for the
coverage Valficsiiou and that failure to azure coverage under seeiioa 25A of MGL 152 can lead to the ivaposiiiou of mmival pcnallics
oomistru of a fine of up to S 1,500.00 and/or imprisonmcat of up to ow year and civil prnaltia in ti,,form of a Stop W oric Ofda and a
fum of s 100.00 a day tgaiast me
f
For dcputr�use mly
permit Number
Lot n
Slgnamm of Liccn-,-r/Prrmitt e
SECTION"8: CONSTRUCTION SERVICES "
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
'`Reg(steretl'vHome'=linprovement'C`o'ntractor ,2,, ;,k'R „ ..`"". Not Applicable ❑
Company Name Registration Number
Address 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 affil-
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
� W!, Owner Ex mptI n
.-.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act
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 thejob 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 personi
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 PROPOSEDWORK((check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
rief Description of Proposed Work: 1gCri--4'-6 Ro v F +
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
sa 'if'Newfidii't acid or}addition`td existing housinfr complet6:the,followinig:
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 r OWNER AUTHORIZATION -TOBE COMPLETED WHEN
OWNERS`AGENT OR'CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject prope
hereby authorize to ac
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.
iqo gA L.0 10 6 A-�;11)J
Print Name
Signature of Owner/Agent y Date
f 1
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 X 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 _ C DON'T KNOWX'—
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:
City of Northampton Stat s Pe p
Building Department ;Curb C�utJ�'�ewa tt r
212 Main Street SewerSept a►1a ��
Room 100 Wat�erlWell�Av�a iab tty �
Northampton, MA 01060 T o Sets ofStrUctura Pass
phone 413-587.1240 Fax 413-587-1272 PIotlSitePians �� i
x
OtherrSpec�fy „
.. . . ..
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:
Map Lot Unit
fI � �itk�
r--°�� �� Zone Overlay District AJ
/' Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lVOni/�1./? V- 50A00 6,1)<''AjAl /t L�iA E
Name(Print) Current Mailing Address:
Telephone
Signature Si
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 ermit applicant
1. Building 0' �o (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
Y
1I LAKI ST . BP-2002-0275
GIs#: COMMONWEALTH OF MASSACHUSETTS
17A-252 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category:roofing BUILDING PERMIT
Permit# BP-2002-0275
Project# JS-2002-0411
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 17946.72 Owner: REAGAN RONALD E&SONIA T
Zoning.URB Applicant: REAGAN RONALD E & SONIA T
AT. 118 LAKE ST
Applicant Address: Phone: Insurance:
118 LAKE ST (413) 584-6368 O
FLORENCEMA01062 ISSUED ON.9/11/01 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 9/11/010:00:00 3960 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo