17C-261 (5) F{ "' tiE C�ixt of 'Nortllulliptoll
B 8 y. �16Hrhn6(tta __
DEPARTMENT OF BUILDI7�C INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORIQZ,�'S,._. MTENSA'nON—�NS CE A < I AVIT
(li censor-/pernv ttcc)
with a prmci al place of usinesslr, idence a .
IV.1�� (sn�tla ty;s[aic/zap)
do hereby certify, unde,r the pans and penalties of pei}uiy, dial
O I am an employer providing the following, v"Orkers compensation cove:a ge for my
employees woriing oil this job
(Cnsuran Cotapv) (Polio:Nu_-atr_r)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the follo%VLng workers compensation policies:
(Name of Contractor) On-siLnanc: CoinpanyiPoiic,- Numbcr) (Expiral o❑ Date)
(Name of Contractor) (Insurance ampamyiPo[Icv N r) (Eapiraaon Date)
(Name of Contractor) (Insurance Company/Pol-cp Number) (ixpiranon Date)
(Name of Contractor) (l.nsurance Company/Pohcy Number) (Expiration Date)
(attach additioml if noocniry to rich d urfixmitioo Pt=n to rill oe"t Vag)
I aim a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:phew be aware that wtnho hcmcowvera who employ pers m to do m+a� coultruaioo m repair wort<oa a dw lling of
tint mcce than three units in winch the bomoowncr rood=or oa the Vouads appurtcn:srl thctw arc oot gcncrahhy ooerda-cd to be
cmployen under the worms ampcaalim Act(G LI 52,%31(5)�aWII won by a homoowvcr far a bCC03C or permit may c-rd—the
hcgil cta us of an omployer under tin W orirjc Cooapee—t Ad-
I undrntaad that a copy of this ctat®cm msy bo forwnrdod to tho Dopartffija of Lodu.r d Aoadm&Offioo of Lc5l— o for tbo
covamgc vcnGcmioo and that Lahore to s eatrc oovc�under saxion 25A of MOL 152 can Iced to the imp051b0Q of aimmal pca&LLi
oomuting of a fine of up to S 150000 and/or of up to one year end civil pmshia io the foem of a Stop Work order and a
fin of S L 00.00 a d_>},y igainA¢�
_ -------
/ F«dcp-rtnrlYil use only
r
Pcmut Number
1. _ —_._-
S, aturc of Liccnscn rr-n ittcz t 3
t
_CT It?'it18-.CMTRt?C'}'IOU"ISER CE
o.1 Licensed Construction Supervisor:---- °T Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signatur Tel hone
�.
�
�� � � Not Applicable ❑
Company Name Registration lumber
Address --- Expiration Date
Telephone
r
SECTI I 1 l-:iN KERS*Cem-F."EUSAT-1614;11tilSURANCE.A011)AVIT tM.G:I_..c.152, § 5C( )
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.
;ned 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
CTIClN S [3 E%Tt1rT1_L04,9J PRQPOSEL?'WORK(check art apolicabfe�
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ 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 Roil ❑ - Sheet❑
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
SECTION 7a OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR!APPLIES FOR BUILDING PERMIT
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
l ; ,:,/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 b d penalties of e Jw
v-
Print Name o`
Signature.ei*wwe A nt 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:
v
r�o," City of Northampton
,,Building Department
212 Main Street
Room 100
Northampton, MA 01062
hone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Srrt z SI` E INI`ORM�r1.(lN
" hls set, farze
1.1 Property Address: ,,"
SECTION"2 PRIOCPERTY`OWI�IEEts111"PIAUTkdRIEI AGENT
2.1 Owner of Recor
Name(Print) Curren Mailing Address: 've e
J (.CJ2,.f��eh1 Telephone
Signature
2.2 Authorized,
lad( f
Name(Print) Curren Malin Address:' ice'
Signature Telephone
SEC11ON"3- ESTIMATED. CONSTR,QCTI.ONi COSTS
Item Estimated Cost(Dollars)to be ��' —° Official Use Only
completed by ermit applicant
1. Building (a) Bui eding!Permit F"ee
2. Electrical (b) Estimated Total Cost.of
Construction from" :6"
3. Plumbing - ui1'ding Permit,"Fe'W
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 +5) Cheek Number
This Sec#ion For Official Ilse Only
Bu!ildine Permit(Number. Date Issued:
Signatpre:
Buildn$"Cnrnmiss'ranerfinspector of Buildings Date.
80 NORTH MAIN ST BP-2001-0337
GIS#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 17C-261 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0337
Project# JS-2001-0550
Est.Cost:$2135.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sg.ft.): 11282.04 Owner: PARKER MARY E
Zoninp,:URB Applicant. Robert Thibodo
AT. 80 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAM PTO NMA01061 ISSUED ON:9128100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 1 PLY RUBBER SYSTEM OVER LAYER
OF DOUBLE COVERAGE
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 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 9/28/00 0:00:00 7396 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo