17C-167 (15) 4�t pT0
r
6 ass itch Rgetts'
m DEPARTMENT OF BUILDr NG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFMAVIT
(IicettserJpermi tt ee)
with a principal place of business/residence at:
(phone#)
(street city/state/2sP)
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 worlang on this job:
(Insumnce 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) (Expiration Date)
r.
(Name of Contractor) (Insurance Compauy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(atlanh additional shoe(ifnccc=juy to include information pertaining to ell ooa4,actors)
(6- 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 while homcowvcrs who employ pca am to do ozniatca=cr cor�ruetion or rryair work on n dwelling of
not more than throe units is tcflich the homeowner resida oc oa the grooads appurtenant thado arc oot fly oocndcrcd to be
employc m under the worker's c=rpcs anon Act(GL152,ss 1(5)),application by a homeowner for a liocnse oc permit may evidcnoc the
legal etnhu of an employs under tho Woriroes Compawation AeL
I understand tful a copy of this ctalcmcai may be forwarded to tho Dcpartaxgf of Industrial Acadmt,'Ofrioo of Isa�raaco for the
ooverage vcrificslion rind that fad=to v_a=coverage uudecr soctioa 25A of MGL 152 can lead to the'imposition of aiMhW pcaaWes
oomiuing of a fine of up to S1,300.00 and/or imprisoamcai of up to om year and civil pcn;jdcs in the form of a Stop Work Order and a
fiaa or:s 100.00 a day against me
For degatMe W nao poly
-. ---— Permit Number
Maps Lot#
„4.. Signa<thrre of Liccnsee/perinittee e
r
ON',8-=CONSTRUCTION SERVICES'
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder : --
License Number
Add ss Expiration Date
Sig ture Telephone
'� ered� e' p ement
1.� pP
Contrh m Not A licable ❑
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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
el -C. '
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 La s and State of Massachusetts General Laws Annotated.
Homeowner Signature 'e
t
ThONk5 �DESCRIPTI0N0�PROPOSED WORK(check all annlicable)
J .iF P . L I H 3
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing d�
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6� If�New�ho>`�s °n�dorrr '�tldition to�eicist�n��-housing,4ciamplete�the�followin�:
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
SECTI6N:7a, OWNER AUTHORIZATION -.,TO BE COMPLETED WHEN
OWNER CT RAPPLIES�'FORw BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters r lative to wo authorized by thi uilding permit application.
Signature of Owner Date
1 p'!` as Owner/Authorized Agent
hereby declare t a the statements and information on the foregoingpplication are true and accurate, to the best of my
knowledge and b ief.
Signed under the pains and penalties of perjury. �¢
Print ame
*gt e of Owner/ gent 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 P -'it/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:
09010 i TN01dWVN180N
SN01038SN191410111183000 Ci y of Northampton
Bu Iding Department r
12 Main Street S
a
zaoz z z �n� �.
Room 100
ampton, MA 01060
51 n �hte3l 7.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
R This section to be completed b office
1.1 Property Address:, � _'
JJffff /J� Map
Zone Overlay D�strct
f
M�kn gam.
Elms District t'CB District__� __• `
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print).� Current Mailing Address:z'6 Telephone
Sign ure
2.2 Authorized Agent:
c,/ ,'�, s, d��a
Name(Print) Current Mailing Address:
fi
Sig ure Telephone
SE TION 3= ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
leted 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: 6100 3 —1 g 0 Date Issued
Sighaiture:
Building'Commissloner/Inspector of Bu';ildings Date
42 HIGH STS BP-2003-0190
CIS#: COMMONWEALTH OF MASSACHUSETTS
F tau-B1Dgk: 17C 167 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2003-0190
Protect# JS-2001-1920
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 31798.80 Owner: MACDONALD NORMA
Zoning:URB Applicant: James Roberts
AT. 40 - 42 HIGH ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:8122102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP AND RESHINGLE 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 Sip-nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/22/02 0:00:00 1996 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo