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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee}
with a principal place of business/residence at:
(phone#)
(streeeUcity/statr/ap)
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 woriang 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 Number) (Expimboa Date)
r.
(Name of Contractor) (Insurance Comparty/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnoxuary to include information pertaining to all coamdors)
'I am a sole proprietor and have no one worlang for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whim homcowacra who employ persons to do makdcnnmcq construction or repair work on a dwelling of
not Moro than throe units in which the homeowner resides or on the grounds appurtenant thereto are not wally ooandomd to be
employers under the wo-kc omv=s4oa Act(GL152,ss 1(5)),application by a homeowner for a liecose or permit may evidence the
legal&1st- of an employer under the Worlca'a C.ompansa6m Act
I undestand that a copy of this rtatement may be forwnrded to tho Departmcos of lndwtrid Acddm&Offioo of In=Tnm for the
coverage verification and that failure to soave covemp under section 25A of MCIL 152 can lead to the'impoudon of criminal penalties
oocnisting of a fine of up to$1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a stop Work Order and a
firm o(3100.00 a day apninst tne.
r
For depot neaw use only
lI Permit Number
gyp# Lot#
Signature of Licensegpermittee Date
d,
SECTION;$-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 7-0m Q L.9 f �7 05 �-���6 '7
License Number
e - s-- % O>
Addr� Expiration Date
�-S Y7��
Signature Telephone
Not Applicable ❑
/0M �-'l
Company Name Registration Number
Address / `� Expiration Date
(�e /✓ ' f 14611 1 TelephoneY '
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...... ❑
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
P T
-ION QEnERQEOSED W-ORK(gheolk all applicpbl e
New House ❑ Addition ❑ eplacement Windows Alteration(s) ❑ Roofing ❑
r Doors�''
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: 0--';7 5 f h M ! o.
Alteration of existing bedroom Yes x No Adding new bedroom Yes K No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ - Sheet❑
�..
a. U of building : One Family— �— Two Family Other
b. Number ooms in each family unit: Number of BathroomsT
c. Is there a garage attathedl?
d. Proposed Square footage of new co ruction. Dimensions
e. Number of stories?
f. Method of heating? �.- ' Fire places or Woodstoves Number of each
g. Energy Conservation Compliance. Ms gck Energy Compliance form attached?
h. Type of construction �.-
i. Is construction within 100 ft. of wetlands? Yes No. Is constru\within 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
Septic Tank City Sewer Private well City water Supply
SECTION 7a•OWNER'AUTHORIZATION -7O BE COMPLETED WHEN
OWNERS AGENT 017 CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize -6+q (DV 11C7 I Q to act on
m behalf II matters relative to work authorized by this building permit application.
Signature of Owner Date
/aM 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 penaltie of perjury.
7-6 r" Q) . f?
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 --;A
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:
w
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
h
1.1 Property Address: �
yf CAF F r�
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v uboy? 9044 0/
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K
Le. n ,Q
cd S 1 / ' 01053 � 4 r /
El mat' L?Sfct emu. ,
SECTION 2-PROPERTY OW NERSHIPAUITHORIZED AGENT
2.1 Owner of Record:
�('CA q K i n C7a j y f' S ck M
Name(Pn Current Mailing Address:
z�^,*
Telephone ��,
Signature
2.2 Authorized Agent:
Name Print) Current Mailing Address:
a SLM - S LO LIl
Signature Telephone
SECTIfJN 3 ESTIMATED CONSTRUCTION COS11
Item Estimated Cost(Dollars)to be Official Use.Only
completed by ermit applicant
1. Building DO (a) Building Permit Fee
2. Electrical (b) Estimated Total Cosh of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) OO, Check Number
This Section For Official USe Onl
Building Permit N�arnber: �'-~` 006 Date Issued:
Signature:
Building Commissioner/Inspector'of'Buildings pate
151 AUDUBON RD BP-2002-0018
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05-047 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2002-0018
Project JS-1999-1794
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Quinlan Builders
Lot Size(sq. ft.): 82764.00 Owner. FAIVRE FRANKLIN R&MARY E
Zoning:RR Applicant. FAIVRE FRANKLIN R & MARY E
AT. 151 AUDUBON RD
Applicant Address: Phone: Insurance:
P.O. BOX 252
LEEDSMA01053 ISSUED ON:716101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 12 WINDOWS REPLACEMENT
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON-UPON VIOLA -Or'
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Siunature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 2986 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo