17C-271 'e
a e �lassactlasrt:�
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'e
Northampton, Mass. 01060 ,~
WORKER'S COMPENSATION INSURANCE AFFIDAVTr
L dill i C a4yL
(licenstx/pelmittee)
with a principal,,place of business/residence at: bl p�7
52-7W-5l
(street/city/staff ehi p)
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 Company) (Policy Number) (Expiration Daze)
( I am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
Olt COA'4 L &4JV A
(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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifneceasary to include information pertniaing to all coatraaors)
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 homeowners who employ pa-;cm to do maiatmancc,a>mructionor repair work on a dwelling of
not adorn than throe units in which the homeowner resides a oa the grounds appurtenant the cto arc not generally oomidemd to be
employers udder the vodka's onion Act(GL152,-s 1(5))�application by a homeowner for a Uocaso or permit may evidrnoe the
legal ctatrra of an employer under the Wodroes Compemdion AcL
I understand that a copy of this uatemeat maybe forwarded to the Depwt,,m2 of Industrial Aaadm&Offioe of la"vnee for the
coverage verification and that failure to seauc covctago under sectioa 25A of MOIL 152 can Iced to the imposition of criminal penalties
oomisting of a fine of up to S1,500.00 and/or imprisotzmctu of up to one year and civil penalties in the form of a StaP Work Order and a
firm of S 100.00 a day against the
For dg artrn�use only
Ptrmit Number
Lot#
Signature of censee/permittce e
Ir
t �?f 13f + N "Y Ft��1t�N' R1i�'
1 Licensed Construction Syu�pervisor: Not Applicable ❑
Name of License Holder AIT2i 5#°Al 6 1q l'34
License Number
GU FAsT H4v .41d n/
W 4 °, 2D12 O a t
Address Expiration Ifate
SignatureV Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECS#Q i �VIII KER "CHAP S llwlN:IN t"tC AFOIDi�1fIT(1GI. L c,:152, iC(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.
NOMENNEENOM
igned 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
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ ] Other[ ]
Brief Description of Proposed Work: 04,12, !4efS ®N' /yecol l54✓4/1# 7-d-M 6AV ENP 6��oQ �
Alteration of existing bedroom Yes V _No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes _ No
Plans Attached Roll❑• Sheet❑
mi
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?
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
S GTl{)N'7� En]AuTH..... 3 CQI�[iPLET � Y1�H N
OWN,1, 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
R. f Sk , as Owner/Authorized Agent
hereby decla a that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
igned under the pains and penalties of perjury.
�l l�644f — � V�4T12ps NQ�
Print Nam
c)
Signature of Own /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 X 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:
s
i� City of Northampton
CV2720 s '
g�_. uilding Department
212 Main Street
DEPT OF BUILDING INSPECTIONS Room 100
NORTHAMPTON.M CiGSO 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
SIN 1f ICflRITI N
1.1 Property Address:
L, G LEI
C l? RSH1tP/A1U H'QR EN
..
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone S_D /
Signature CS.L
2.2 Authorized Agent: dlc� 7
A1044-16 sir
Name(P Current Mailing Address:
'03 52-7 3�s�
Signature Telephone
9
Item Estimated Cost(Dollars)to be ifol tJ Only
completed by ermit applicant
1. Building (a) Buildin' Permit F�
2. Electrical
(b) tinated T1 rt
3,
`rQ 3 ._rUCt�p
3. Plumbing ng# rmit Fie
3
I
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+5) Chcic...__ tber
do ."''d.official;QWO n1'
rajll�in erm�i N'd ber
-,-» --�
g U., °.
Date 1SSUed
5ti— AtLlre 3I '• d}'"R AS
3
3u�ld�� .CQ,,,rna& nln „ec# r3. hull., rls Date„
P
File#BP-2001-0524
APPLICANT/CONTACT PERSON MICHAEL MATRISHON
ADDRESS/PHONE 10 STRONG ST (413)527-3959
PROPERTY LOCATION 41 LILLY ST
MAP 17C PARCEL 271 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid a
Typeof Construction: REPAIR PORCH STEPS&SONO TUBES
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included:
Owner/Statement or License 074136
3 sets of Plans/Plot Plan
THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedibased on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § —w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Consery at. Commission Permit from CB Architecture Committee
Q 1 NGJ V
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.
r
41 LILLY ST BP-2001-0524
GIS#: COMMONWEALTH OF MASSACHUSETTS
✓Iap:Block: 17C-271 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0524
Project# JS-2001-0908
Est.Cost:$500.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: MICHAEL MATRISHON 074136
Lot Size(sa.ft.): 11499.84 Owner: SPARLING DOREEN
Zoning_URB Applicant: MICHAEL MATRISHON
AT. 41 LILLY ST
Applicant Address: Phone: Insurance:
10 STRONG ST (413) 527-3959
EASTHAMPTONMA01027 ISSUED ON:11/28100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH STEPS & SONO TUBES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Deaartment 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 11/28/00 0:00:00 591 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo