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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WOM ER'S COMPENSATION INSURANCE AFMAVIT
(licensee/permitter)
with a principal place of business/residence at:
(phone;#)
(s tr eet/ci ty/stately p)
do hereby certify, under the pains and penalties of peg3ury, that.
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
- (Insi=icc Company) (Policy Number) (Expimtion Date)
am a sole proprietor, general contractor r homeowner circle one) and have hired
the contractors listed below who have the follo �orkelfrS compensation policies:
(Name of Contractor) (Lasurancc Compaiiy/Policy Numbcr) (Exprmtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance. Company/PoLicy Numb(ti) (Lxpiraaon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attadr ad�itioaal sheet if n< tuy to include infocrua ion pertaining to all oocrhracton)
O I am a sole proplietor and have no one working for me.
(kr-l-am a home owner performing all the work myself.
NOTE:plcasc be await that while homcowvas who crnplvy periom to cio ma ntcaancr cc','- uC on or rrpair work oo a dwelling of
not mote than thmo trait,in wfrich the homoowvcr rmdca or oa the groucrh appurtenant thtra arc oo(gaxrally oomidcrcd to be
cmploycr3 under the work--es ccut{xr_saticu Ad(GL152,sa 1(5)�applicallon by a hancow wr far a 6ccrise cc permd may cvi&noc the
leSl rtatLu of an employer under tho Wocicor'e Componsation Act
I understand that a copy of thin 0 trMCOt may be forwarded to tho r?eputmcni of In&ustrial Aoci&-&OHtioo of Lunuanoo for the
covcragc vaificatioa and that failure to s".x covcrngo uadcr section 25A of MOIL 152 can read to the imposition of criminal penalties
consisting of a fmc of up to S 1,500.00 arIN"imprisonment of up to one ycar and civil pcaaltia in the form of a Stop Work Order and a
fine of 5100.00 Idly tgurast me.
For dcps�use only
Permit Number
Map,f Lot�
Si of Liccnscc c ----
� M
SECTION 8-;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ERs erect l melm`provementContc�pr . .. . ~ _.. _�. � Not Applicable ❑
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...... ❑
Owner' X-eff-Mioh
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 4N Local Zoning Laws and State of Massachusetts General Laws Annotated.
0 Homeowner Signature �Gwyf�
QS V
SECTION S--DESCR]PTIONjOFPROPOSED WORK check-alhapalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: 105bAl 0% INCA bUf�1lY1 1— �1fC 2U_('e_ Ins et-r-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a:"IUNewJKouse a"nd1 dition°to:ezisting; dousing; complete_the'foI i`nk:
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.AGE NT'OR°CONTRACTOR APPLIES FOR'BUILDING`PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, iryvIl matters rela to work authorized by this building permit application.
Signature of ner 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 and penalties of perjury.
Print Name
Signature of Owner/Agent 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 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:
Tk
FF4)
of Northampton
r- Iding Department Gear.
i 2 I' 6 LvC2 12 Main Street
SE Sew e
Room 100 e
ort ampton, MA 01060
P�
DEPTOFBUILDING I;Tl,413-5 7.1240 Fax 413-587-1272 l'I'o IStte In
NORTHAMPTON, �A 0
Otftier5pe .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This sectiofr to be completed by office
1.1 Property Address: N�,
fi �e211n rt�,�f(l S1 Map NL'ot �3 unit
4r
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED;AGENT
2.1 Owner of Record:
Valke "D w( 014 nec�V�U>✓ a t1 S l®fwe— C) 06 z
Name(Prin Current Mailing Address:
Telephone
Signature _
2.2 Authorized Agent:
Name(Print) 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. 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: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r �
73 NdRTH MAINS ' BP-2003-0328
GIs#: COMMONWEALTH OF MASSACHUSETTS
ian:Block t 1C- CITY OF NORTHAMPTON
Lot: -001
Permit: Q u i U g
Category BUILDING PERMIT
Permit# BP-2003-0328
Project# JS-2003-0550
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg. ft.): 19819.80 Owner: O'DONOGHUE PHILIP C&
Zoning: URB Applicant: O'DO N OG H U E PHILIP C &
AT: 73 NORTH MAIN ST
Applicant Address: Phone: Insurance:
73 NORTH MAIN ST
FLORENCEMA01062 ISSUED ON.9126102 0:00.00
TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE INSERT
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 9/26/02 0:00:00 1837 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
73 NORTH MAIN ST BP-2003-0328
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17C-247 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2003-0328
Project# JS-2003-0550
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 19819.80 Owner: O'DONOGHUE PHILIP C&
Zoning:URB Applicant: O'DO N OG H U E PHILIP C &
AT.- 73 NORTH MAIN ST
Applicant Address: Phone: Insurance:
73 NORTH MAIN ST
FLORENCEMA01062 ISSUED ON.9/26/02 0.00:00
TO PERFORM THE FOLLOWING WORK:INSTALL FIREPLACE INSERT
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:QK
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLA ON OF
ANY OF ITS RULES AND REGULATIONS.
11010
Certificate of Occu an Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/26/02 0:00:00 1837 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo