17C-194 (6) O 4��MPTO
.� °
B fl Gl-it 7 elf wart4aillpftltl
� B �asaachttactta'
e -
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1,
(IicenserJpermiuee)
with a principal place of business/residence at:
(phone#)
(st=U6ty/statrlap)
do hereby certify, under the pains and penalties of pequry, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O I am a sole proprietor, general contractor (Gomeowner` cle one) and have hired
the contractors listed below who have the following worker's compensation policies:
/I $(/I 4___ ("i-E-L
(Name of Contractor) (Insurance Company/Policy Number) (Expim6oa Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach add?doml shod if noccuary to include infonmstioo pertaining to ell ooatna r3)
O I 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 bomcowom who employ pczxo=to do mxinknznrx,washuction or repair"-Ork on a dwelling of
not more than three units is which the hamoowncr midi or ou the grounds appurtcnaat th,-c o arc not geocimily comukrcd to be
employ=under the workres oompcnsatioa Ad(GL152,m 1(5)),application by a homcow=for a Berme or permit may evidence the
legal ctatur of an employer under the Workces Compeo si Ate.
I underdsnd th:i a copy of thus rhlemmL may be forwarded to the Dcpartmcni of Ind+rsuid Atcidm&Ofboo of Inarus:noa for the
cov=ge verification and that failure to s==covaago under section 25A of MGL 152 can lead to the imposition of criminal penawes
ooruisting of a fine of up to S1,300.00 indict imprisonment of up to one year and civil penzltia in the form of a Stop Work Order and a
fine of S 1 .00 a day agttinsl me
"
F d uao only
For
30� WP-#t Number Lot#
• D !v1-�r
Si of Licensee/Permittee
SEC1'lOhl � CbNSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1. WORKERS COMPENSATION 1 NSURANCEAFFIDAVIT(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"certi s and assumes responsibility for compliance Aith the State Building Code,City of
Northampton Ordinances, State an ocal Z ' g Laws and e of usetts General Laws Annotated.
Homeowner Signature
SE TON 5 DIr G < :0: OO PR POS � IVI it fi k1,6110,aggli'da ble „ h
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: !2�/r7oi//fj- p� O d!� ��/ yCf ,� S/a/ v�"
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o- Sheet❑
f Ne . h=. d AOMORI= iff ii!i ° com 1eeX61 Fie fojjbw Jh
z.
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.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 7 OWMER AUTHORIZATION TO.,BE COMPLETED WHEN
OWNERS AGENTOR CO IES 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::_
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 a penalties of perjury.
Print Name
Signature of Owner/Agent Date
t
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 Fro
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:
I
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
1.1 Property Address: i$ #i'
MY a is t
{1� � �i`✓� /���' / I // ��� � Z�@�����"��� ��� �N rl8 �DIS#r ��u' �t``h f �
Eln�t District �, �
SECTION 2-,PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record- '
/�'/ 1 v tf/Z
Name(Print) ' Current Mailing
Telephone Signature
y1f,11--� 4- 171s7
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3'- ESTIIVIATED'°CONSTRUCTION:COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical L/ (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) do ..— Check Number r
This Section For.Official Use:Onl
Building Perrnit;Number:i Date Issued: .
Signature:" BulldlragFComrjtlss�oner/Inspector of Bu
ildtngs
Date o
BP-2003-0334
GIs#: COMMONWEALTH OF MASSACHUSETTS
rM CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0334
Project# JS-2003-0562
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot size(sa. ft.)5967.72 Owner: NORRIS SCOTT A
Zoning:URB Applicant: NORRIS SCOTT A
AT. 20 WILDER PL
Applicant Address: Phone: Insurance:
20 WILDER PL (413) 586-1341 ()
FLORENCEMA01062 ISSUED ON.9130102 0:00:00
TO PERFORM THE FOLLOWING WORK:I N STALL V1 N Y L S I D I N G
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 9/30/02 0:00:00 727 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo