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DEPARTMENT OF BUILDDT G INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A + ' AVTT
(Ii cen-Sec/permi tree)
with a principal place of business/residence at:
r ,
/�
# P-0 1 ..r ism —(phone
(st1 eeei/city/s-tat.e/ap)
do hereby certify, under the pains and penalties of pe:quuy, that:
( ) I aml as employer providing the following worker's compensation coverage for my
employees working on this job:
(I-n,;iL c-- Company) (Policy Number) ira n Date)
I ini a sole proprietor, general contractor or homeowner (circle one) and have hared
the contractors listed below who have the following worker's compensation policies:
(I`Vme of Contractor) (nsuranoc Cornpany/Policy Number) (Expirndon Date)
(Name of Contractor) (insurance Company/Pclicy Number) (Expiradon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiraion Dale)
(Name of Contractor) (Insmlaacr Company/Policy Number) (Expiration Date)
(mach dit on�1 sheet ifntc.-SS�.ry to include information P:*.auiug W all e Itracton)
( 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 awart that whilo homcownm who cmpiay pazaas to do ma•,tcal c,,c= ruction or repair work on a dwelling of
not more than thr� units in which the homeowner rmdc3 or on the grounds appurtenant th,c arc not gcnerilly ooasidacd to be
employers under the works.o=*cmdico Act(GL152,ss 1(5)),application by a homcow ncr for a liocnso or permit may cvidcnoc the
Iegxl ctwu of an amployor under tho Workcez Compoosation Ace.
I undcrstaad that a copy of thin ztatcmcat may bo forwarded to tbo Dtvwtmcn2 of Indaut ial A md=&Of&oo of Inauaoce for dw
ooverag verification and that failure to(rates coverago under section 25A of MGL 152 can kid to tho imposition of criminal pcnaltics
ooasistiag of a fine of up to S1,50o.00 and/or imprisonment of tip to one year and civil prnaltia in the form of a Stop Work Otdc and a
fim of 5100.00 a day agpimt me
-' EtIF", atal—only
* tunber
_ Lot 4
Si itttre of L iccnset'lPermittce
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address j}motj p }�9 ,
Expiration Date
41r, •' I as" d `.{eJ't a�' j 9 �;>s. ' 4P
Signature Jelephone
9 R � Not Applicable El ums
@d l U Tl� t q r M.
Company Name Registration umber
_ /
,� � "J
Address Expiration D
i 'on ate
Telephone " 1 Q ci o o 3
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MGL. c 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidaait,
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No.. ••• ❑
u 1 � .. ,
11: � eO�vn �rEempt><on
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 strictures 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 refererc;e 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 DESCRIPT1bN OF PROPOSED".'WORKi(check:all aoplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:'$Ltd F°/� t°". t `` .ace + f t f <f'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 11 . Sheet
6a" Ifitl�e`�ni�h'o�use ' lidor�aii"tlition.to°`eici"s"ti`ng�fiors��ng;°com�lete° tho.�fol'lowiri :
r
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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a ..OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS::AGENT'OR CONTRbCTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize C _ to act on
my behalf, in all matters relativ,elo work aut orized by this building permit application.
Signa 're of Owner Date
I, 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 and penalties of perjury.
In D,&w.SeeP
Print N me
Signature of Owner/Agent Da
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 Speci 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 `
B.u' epartmenturs
1 in Street 5 e
o 100 a
Northa i p n, MA 01060 two i ens a ° a
FDboae..,4MMOO Fax 413.587.1272 i'io !$ite n
Ot( er Spotfy �
APPLI "A'f0`id"X "� T, AL ER, REPAIR, NOVATE R DEMOLISH A ONE OR TWO FAMILY DWELLING
�«
SECTION 1 - SITE INFOR
1.1 Pro er ddress: �,�
This section to befcompl�et d�b�yftce
m
x r
M +e'
Zone Overlay Districf
Elm St. District CB District'
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Ci,,rrerit Maili,na Address: t/o
Si nature �� Teleph� f 7' f
g l �C. ✓ f
2.2 Authorized Agent:
Name(Print) Current. Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS '_ ✓a{
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electn.-.al (b) Estimated Total Cost of
Cc istruction from 6
3. Plumbing Building Permit fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Cherck Number U This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Comm issioner%Inspector of Buildings Date
File#BP-2002-0733
APPLICANT/CONTACT PERSON Tom Dawson-Greene
ADDRESS/PHONE P O BOX 556 (413)296-4421
PROPERTY LOCATION 46 NORTH MAIN ST
MAP 17C PARCEL 256 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Buildinp,Permit Filled out
Fee Paid
TyDeof Construction: REMODEL KITCHEN&BATH&SHEETROCK CEILINGS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 013633
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§_
Intermediate Project: Site Plan AND/OR _Special Permit With Site Plan
Major Project: Site Plan AND/OR _Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit _ Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissi
Z 12-0d�-
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
46 NORTH MAIN ST BP-2002-0733
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17C-256 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0733
Project# JS-2002-1204
Est. Cost: $37000.00
Fee: $185.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin: Tom Dawson-Greene 013633
Lot Size(sq. £t.): 22389.84 Owner: BRILL ELISSA
Zoning:URB Applicant: Tom Dawson-Greene
AT. 46 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 556 (413) 296-4421
CHESTERFIELDMA01012 ISSUED ON:2127102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & BATH & SHEETROCK
CEILINGS
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 2/27/02 0:00:00 7600 $185.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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46 NORTH MAIN ST BP-2002-0733
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-256 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0733
Project# JS-2002.1204
Est. Cost:$37000.00
Fee: $185.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Tom Dawson-Greene 013633
Lot Size(sq. ft.): 22389.84 Owner: BRILL ELISSA
Zoning: URB Applicant: Tom Dawson-Greene
AT. 46 NORTH MAIN ST
Applicant Address: Phone. Insurance:
P 0 BOX 556 (413) 296-4421
CHESTERFIELDMA01012 ISSUED ON:2127102 0:00:00
TO PERFORM THE ALLOWING WORK.-REMODEL KITCHEN & BATH & SHEETROCK
CEILINGS
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• J�/� House# Foundation:
S �'- ' Driveway Final:
Final L Final: C)J(A-
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 6 K
THIS PERMIT MAY BE REVOKED BY THE �TY OF NORTHAMPTON UPON VIOLA ON OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Signature:
Fee Tyne: Receipt No: Date Paid: Check No: Amount:
Building 2/27/02 0:00:00 7600 $185.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo