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board of Iittildint; Re"Iflations and stanclar(Is
AtI
BOARD OF BUILDING REGULATIONS
ij HOME IMPROVEMENT CONTRACTOR License: CONSTRUCTION SUPERVISOR
Registration: 102821 Number: CS 0156293
Expiration: 7/2!2004 Birthdate: 10/1111940
Type: DC3A Expires: 10/1112002 Tr. no: 10933
BELANCjEl2 NOME IMPROVEMEN Restricted To: 00
serge BELANGER SERGE B BELANGER _
173 MAIN S)T. AF'Y. C f,..._, -;;�;,= r a, 173'MAIN ST APT B
E&Aha raptor�, MA 01 027 �dministr at,�r EASTHAMPTON, MA 01027
Admir�atrator
c
M
��1tAMPTO
.�O e
b 8 GrXt� laf 'Wort'4a11tpf oll
9 6 �a541iC12nartta'
DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE ATTIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
175 /yf IW si 407C. /'7at/
(stm t/city/state/;iP)
do hereby certify, under the pains and penalties of per3ury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job: �e
(Insurance Company) (Policy Number) (Expirafion Date)
O I am a sole prop rieto<gerleral contracto homeowner (circle one) and have hired
the contractors listed below e following worker's compensation policies:
(Name of Contractor) (I-nsurance Company/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Compauy/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E.\-pima on Date)
(Name of Contractor) (Insurance Comparry/Policy Number) 'Txpim ion Date)
(attach additioml z'cd ifnccu uy to i CWC Mforuiatioa pertaiu to all coaradon)
O I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:picaac be awarc that whilo hom:o"Mas who cmpioy periom to do mxmtcaigcc,cm str=oa or repair wvcic on a dwelling of
not niece than thruo un 3 is which the hou»owmcr r=dcj or oo the grcwne+,app,rtcmni thactn art not golly coccnidcrcd to lx
employers undo the wort s cos t oa Act(GL152,,�s 1(5))�,appticaAon by a homoow=for a license or permd may vvidcaoc the
legal rtatnc of an employor under dw Words Compms ion Act
I understand turd a oopy of this r e,.,.,�.,r may ba loswardi d to tbo Dtputn cnt of Indsutrial Attid�Qffioc of lnn rs for tho
covmx verification and that failure to sure coverage undex scctioa 25A of MOL 152 can lead to the imposition of criminal peaall:
oonsistiug of a fine of up to S1,500.00 and/or impriwanxni of up to one ycr and civil peaaltics is the form of a Stop Wcric Or&--and a
find of:S 100.00 a day against me-
For dcpsrtU�uio only
Permit Number
NfaP# Lot#
Si of Liccnsce/permiace / e
P 77777777,
SECTAION 4s-,,COIjST, OCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 70
Name of License Holder
License Number
Z 73 /Yep-lk' �PTC' - iallI z
Address Expiration Date/
Signatu Telephone
v mm cement Contrafor Via`= d ,,, Not Applicable ❑
Company Name Registration Number
7--? /fy s 7 ark
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.
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-vear 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 DESCR(PTI, iPROPOSEDkWORK(cheek all aaalicable)
New House ❑ Addition ❑ Replacement Windows [Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 0-I'D 4I SkA'01 a 16 fC^
Alteration of existing bedroom Yes V"No Adding new bedroom Yes 4 No
Attached Narrative❑ Renovating unfinished basement Yes '" No
Plans Attached Roll ❑ - Sheet 0
s Cf New'fiou a antl ors"'dd'it�on°'to ezistFng housing.`compI6 a th614611 M :
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 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 authorize __ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Sign "ure of Owner Date
as Owner/Authorized Agent
hereb cleco'r b that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge Vd belief.
Signed under the pains and penalties of perjury.
tla1, N 1 Meae xcLh2
Print Name
Signature f caner/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 0
Setbacks Front '
Side L: 0 R: L: R:
Rear 3 ,00
Building Height i
Bldg. Square Footage r 7'F,z %
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 1,"- 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 V
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 orthampton
uA i Department r
224 ain Street
- r? I m 100
North mp n, MA 01060
phee � -12 0 Fax 413-587-1272
n
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT_ ION 1- SITE INFORMATION
This sections°tofbe completed by'"offrce
1.1 Property Address:
Ma '^ ,' �LO.
�Ouerlay°Distrtct �
Zone �
Elm St. District GCB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT>
2.1 Owner of Record:
Name(Print) Current Mailing dress: �,I
Telephone
Signature –
2.2 Authorized Agent:
�,q— lY�,/4 y f'k
Name(P int) Current Mailing Address:
gnature'f Telephone
SECTION.3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building ' .100 (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) Ole Check Number
.This Section'For Official Use Only
Building Permit Number _ Date Issued:
Signature::
Date.
Building Commissioner/Inspector of Buildings ,
WNW
.Aux BP-2003-0259
G1S#: COMMONWEALTH OF MASSACHUSETTS
6 0 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003.0259
Project# JS-2003-0457
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SERGE BELANGER
Lot Size(sa.ft.): 87120.00 Owner: MEEHAN JOHN T&SUZANNE B
zoning: SR Applicant: SERGE BELANGER
AT: 420 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
173 MAIN ST - APT C (413) 527-2414
EASTHAMPTONMA01027 ISSUED ON:9112102 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:
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 9/12/02 0:00:00 4924 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo