17A-278 (5) 0�`ti Crrf� of �lfirJr flfr�111}]tOn
4 E 1K 3 a a(h n 5(t1a
d DEPARTMEI,T OP BUILDrNG INSPECTIONS
212 Main Strcct ' Municipal Building '
Northampton, Mass. 01000
WOIUKEWS CoMTENSA-EON MSURA-NCE AFFM,, Z rr
with a principal place of business/residence at. f >
(SLSC t�Clty/51,ULIDp)
do hereby certify, under the pains and penalties of pegury, :hat
( ) I am au employer providin- the followine \vorher's compensZ bon covcmgc for Irly
emplovecs wor�mlg on this job
00 to o
(La=-nc2 Comu,=V) (Polk:Nu-mirr) (F_;,2;iration Daze)
( ) I am a sole propnetor, general contractor or homeowner (circle one) a7d have hired
the contractors listed below who hzve the follo%V' worker's cou�oenszuon policies:
(Name of Contractor) (Insn ranc Compan}vi cue;NumLY;) it=xr,rauon Date)
(Name of Contractor) (Insirancc ComoanyiPojc-v NumLcn) (i.api-moon Date)
(Name of Coumclor) Rasuraacc CompU).1Policy Numbu) (ENpimuoo Date)
(Name of Contractor) (Insu any Compury/Policy Numbcr) (Expiration Date)
(aaach�dditioaaJ r3crt if nooc—ary w Lnfoc=U-%oo pcxtn-ivang to it oo2rn,c..o:3)
O I am a sole propnetor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plansc be-w-4m that w11210 6om00Vwcr3 woo cmp{oy pcz o to do o=; is , cr-a nizvzuoc cr rcpair work oo a d,--LLLng of
not mom than Lbreo uaru in wtveh the bomoowncr rrsdco a coo the grouter appurteaani thedo ere ooe g oaally oocridar d to be
employrs3 under the s oampc--z-4oa Aci(GL152ss 1(5)),npplirz.6oa by a bomcowva for a Gccwc or pama may cvidcaoc the
IcgaJ atsnie of an omployor uader dio Wock. ,a Compo.:I-j n Art
I uod--nd d3-z copy of th6 ral.cmcol may bo forwarded to Lb.Dcpurtmcot of Indi!_u;a1 Aoo&.&Offioo of la iu,<oaa for d-
coven vcril c:dioc and that L durc to acatrc covaAgc under soctiou 25 A of i t4L 152 crn Ind to tbo imposaioa of mmmtt pca&Wcs
oomining of a fine of up to S 1,500.00 and/or i>xrpxiso�of up to one ytar fM civil pcwhic3 in dic form of a Stop Work Order"a
f=o(:S 100.00 a day aguaA me
Foc doputmaYiJ uac coly
Permit?lttmbcr
igna of LictliscclP ucc ��
;ZECTIO -CONSTRUCTION SERVICES
�N�8-CO�N
I Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
AIR%
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 affidavit
will result in the denial of the issuance of the building permit.
AoW*ignedAffidavit 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.
onsibili fi
The undersigned"homeowner"certifies an o,assumes resp i ii or compliance with the State Building Code,City of
assumes r
Northampton Ordinances,Sta �2onin7nd to f usetts eneral Laws Annotated.
Homeowner Signaturek/7"?SNzX4 as
' 4
D 5 [ F:. R OS D heck aI a li bl
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: _01 0 Ck ti
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
y" v
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?
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
SECTION 7a,OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby auth rize L t'�/Z/� 1�f ET ' to act on
my b i all ma elative r'k a razed by is building permit application.
3 - 30-01
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.
igned under the pains and penalties of perjury.
:Print Date ignature of 0 er/Agent ✓ C✓
> 4
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:
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, R N A R ONE OR TWO FAMILY DWELLING
al
AUG,j
- 4 2004
SECTION'1-SITE INFORMATION i i --
1.1 Property Address: DES Dr t?ii1l� >a 5 S h tip c !mt by ff�
iDo/i1 fl 6j4141U(J0t0 I)i L L HA>-L)
20�
�
5s � S f - y
-01,7 l U lrn st t istrt�t C t IstC t_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
ame(Pr' ,t) Cur n M 'ling Ad ress:
Te hon
Sign
2.2 Authorized Agent:
k 'A v Ile* RA C2
Name(Print)—�— Current Mailing Address:
S-3- � - 6 '? ,
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COS T5 t j} O
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 'v� ,o dc) (a) Building Permit Fee
L "°
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
wilding Permit`Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
i
1
55 OAK-ST BP-2005-0151
GIs#: COMMONWEALTH OF MASSACHUSETTS
7A-278 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0151
Project# IS-2005-0165
Est.Cost: $10000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq. ft.): 12240.36 Owner: DILLARD SHANNON COKER&
Zoning:URB Applicant: Larry Paquette
AT. 55 OAK ST
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:8111104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 Occupangy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/11/04 0:00:00 3520 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo