17C-219 (5) Q--�rWrpTo
A a Crzf� of 'Waz#fl�ntptnll
as �iEf ACh ttECl1E
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORT R'S COMPENSATION INSURANCE AFITAMAVIT
(li cen-see/perm�iz ec>
with a principal place of business/residence at:
(phone#)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance CompaIIy) (Policy Number) (Expiration Date)
V,Y<m a sole propriet , general con or homeowner (circle one) and have hired
the contractors listed belo ve the following worker's"compensation policies:
(Name o Contractor) (Insurance Company/T�'Ottcy Number) (Exp lion cite)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiooal shod ifnoccssary to include information pertaining to all ooOtratlors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plwe be aware that wbilo homcoxvm wbo employ prom to do rra irif m,=c corr r on or repair work on a dwelling of
not more than throe units in which the homoowncr raids or on the Rounds appurtonru3 thereto arc oo(generally oomidacd to be
Cmployrrs under the wmicet's.ration Act(GL152,Ts 1(5)),application by a hotncow na for a b0cn5o or permit may evidcocc tho
legs!status of an employer under the Workaes Compoosatioa Act.
I understand the a copy of this chtemcat may be forwarded to the Departmm of Dial Aocidmt&011ioe of Imsuwoco for thn
coverage verification and that failure to secure covttago u uder scetioa 25A of MGL 152 can Icad to tbo imposition of aimin pemW-
eornisting of a fine ofup to 51,500.00-Nor impr6oament of tip to one year and civil pcnxItia in the form of a Stop WorkOrdt;and a
lino of S 100.00 a day agniust mc.
�j For —ooly
l
permit Nu mt
t Mag#
Lot#
Signature of Licim JPermittee
SEGTION:B=,CONSTRUCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
emen y. r r: _ 11131111M Not Applicable ❑
Company Name Registration PJu m er
Address Expira i n DAle
Telephone�' G �1�2
SECTION 10 WOxRKERS1,`C,QMPENSATI0N 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 t wilding 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
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
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 0
6a.nlf�New�h�oiase�antl or�addit'ion to°eziSting fiousin�'°corriplete�the:fol owing:
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
Llhereby authorize _- F�- �� 11��i to act on
my behalf, in all matters r lative o work authorized by this building permit applica on.
r -
ignature of Owner Dat
I,
ell" /, as Own r/Authorized A
hereby declare that the statements and information on he fo going application are true and accurate, to o my
knowledge and belief.
Signed u er the pa' and penalties of perjury.
Print ame
$ignature of Qwner/Agent At .
a
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:
d
City of Northampton
Buildirl,r, Department C_1rbC O w
- X12 Main Street S r%Sery.ir
Room 100 a e.rlV oil,
- Northampton, MA 01060 T Se IN
phone 4 -587-1240 Fax 413-587-1272 Plo ISite
v 4
O: erSpect.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING `
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This sectiori to be completed by office
s
6 Map
Zone O"V6rlay°District:
Elm'St. District CB"""'Oct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Z ��
Name(Print) Current Mailing Add_�s
Telephone
Signature
2.2 Authorized-Agent:
N me(Print)'-- 7 Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee'
2. Elecirical (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 U _
l This Section For Official Use Only
Building'Permit Number:r Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date,
164 NORTH MAPLE ST BP-2003-0979
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-219 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category_ BUILDING PERMIT
Permit# BP-2003-0979
Project# IS-2003-1575
Est. Cost: $12890.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: PHILIP BEAULIEU HOME IMPROVEMENT 100073
Lot Size(sq.ft.): 19035.72 Owner: VENNE RICHARD W&RHONDA J M
Zoning:URB Applicant: PHILIP BEAULIEU HOME IMPROVEMENT
AT. 164 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
217 Grattan St (413) 592-1498 Workers
Compensation
CHICOPEEMA01020 ISSUED ON:518103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS
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:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/8/03 0:00:00 7860 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo