17C-246 (6) • ►
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ,y
WORKER'S COMPENSATION INSURANCE A FTDAVIT
(licenserJpermittec}
with a principal place of business/residence at:
�z APO oC -444* oia9 5 (phone#),_s-/0 X'; f
(s treef/ci ty/state/zi p)
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 working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle on(-,) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Exp mboa Date)
+r.
(Name of Contractor) (Insumce Company/Policy Number) (Expiration Date)
(Name of Contractor) amsuranc:z CompanyiPoLicy Number) (E�Y mr on Dale)
(Name of Contractor) (Inmranee Company/Policy Number) (Expiration Date)
(attach additional ilxr(ifnecc iy to include inforrnstion pertaining to all occdia r3)
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 thst w'-silo homcowvcra who ctriploy pons to w n•jLftzrLjJjCr wn=ct on or rep cu work on n dwelling of
not more than throo units is which the hemoowncr midis or on tho gvu,•xL,zpptutenarA ihetcto arc not gcoa-a ly coaridacd to be
cmploycrs undo the woeKctts. lion Act(GL152,s31(5)),application by a homcowna for a liccasc a pcm1a may cvidcnoc the
legal etat u of an omployor under the Woriceta Compa cation Act.
I undcntand th:i a copy of this uatcmcnt may bo forwarded to tho Dcpnrtaxot of industrial Acczdl-&Offico of Ia;ur.oco for the
coverage vcrif cation and that faihtre to s xztre covemgo under scdioa 25A of MGL 152 can lend to tho imposition of criminal pcualt es
coo3utnn of a fine Of UP to 51,500.00 andlor bmprboamcnf of up to one year and civil pcn2Ncs in the form of a Stop Work Order and a
firm of S 100.00 Idly against mc-
For dcpatl er only
um
permit Number
Wp;I Lot 4
Si of LiccnsedPcrmittee Date
Y �
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
` Re is @merle inargue�neContracto �E � a r Not Applicable ❑
g
Company Name z Registration Number
Address Expiration ate
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...... ❑
WE. om O R ;rie�E�e � ption
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 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 3 DESCRfPTrO'NOF PROPOSED WORK(check all aaalicable)
4WDa " �a
New House O Addition ❑ Replace n Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: ::-V L- r�Lfd LA-1 �` S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet❑
fa, IfNewho sera°ndor�atlditiontoexi'sting=Fiou"s"ins, corri"pletethe'followirl :
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? I I
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?
In. 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 ORICONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _. to act on
my behalf, in all matters relative to work authorised by this building permit application.
Signature of Owner Date
as 0 r/Au�dA hereby declare that the statements and information on the foregoing application are true and accurate to
knowledge and belief.
Signed under the pains and penalties of perjury.
"'k Print Na
Si ure Own Agent ate
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 KNOB^! 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:
4 X02 ity of Northampton
SEP 2 uilding Department ' rb
.212 Main Street 5
p>Ft of eaull.DING NSFECTiONS I Room 100 a
NORTHAMRTON MA 01060
Northampton, MA 01060
phone 413.587.1240 Fax 413.587-1272 ;I,-iotl5ie a N
tiQ e s F _
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
i This section to be completed by=office
1.1 Property Address: ��
V ' n
/V a' �IJ"�JI�J S! ►�wC Map loth k Nr
�^�s � ,mar x"a`t'e
t
Zone Overlay D�str ct
5
Elm SC`Oistrict_ CB-District
SECTION"2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailin Address:
Telephone
Signature
2.2,_
7D—,4
Authorized Agent: _ Ctva-5-3
Nam (Print) Current Mailing Address:
nature 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. Electrical (b) Estimated Tetaf Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3+ 4 + 5) /Q�Z a Check Number
.This Section For Official Use Only
Building Permit,Number: Date Issued:
Signatures
Building Commissioner/Inspector of Buildings, Date
I+I �tII [Air '3x` BP-2003-0304
GIS#: COMMONWEALTH OF MASSACHUSETTS
fi..r Yn CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate og ry: BUILDING PERMIT
Permit# BP-2003-0304
Project# JS-2003-0518
Est.Cost: $1020.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sa. ft.): 20560.32 Owner: HAIRSTON ANDREA&PAN WELLAND
Zoning:URB Applicant. John Corbett
AT. 81 NORTH MAIN ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.9124102 0:00:00
TO PERFORM THEFOLLOWING 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/24/02 0:00:00 1429 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo