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DEPARTMENT OF BUIL)rNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORT{ER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee}
with a principal place of business/residence at:
,-SZ ,Qlyirl G r k �� L s /y1a� o�0`� (phone#)
(c,°..Vci1,yhIaif: p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers 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:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compar,y/Pohc- Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shed if nxcissry to inchule infortnsIIoa patainiag to all ooatradon)
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 whilo homcov,-0=who employ pawns to do m-�wastr=oa or repair work en a dwelling of
not more than throe units in which the homeowner raids or oa the gouods appurtenant thercto are not generally ooasidard to be
cmployrrs under the wori,aa cca*c:asatioa Act(GL152,ss 1(5)),application by a homeowner for a Eccnx or permit may evidcoce the
legal crams of an employee under the Workcez Compeosatioa Act.
I understand dui a copy of this rWcmmi may be fmva dod to the Dcpertm of Ioaustrial Accidm&OI5oo of Irmo*nos for the
coverage verification and that failure to sm=covcmgo under scctioa 25A of MGL 152 can kid to the imposition of Criminal penalties
oomistin of a fine of up to$1,500.00 anNor i r iso t of tip to one year and civil pcnxWcs in the form of a Step Work Ord--and a
fim of S 100.00 a day against mc.
For dal use only
�L_ Permit Number
of L ermitiee e
�.,
SECTION-$-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
10- vem`e 'n r Not Applicable ❑
Company Name Registration Number
k-K C,e- Si 7�jr1/o
Address j Expiration Date
S n4Pf� 0— --.3 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...... ❑
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-vear neriod 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 _
�. ,y'
SECTION'!v5= DESCRIPTION OF PRO alt applicable)
New House ❑ Addition ❑ Replace en Windows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: L A,.� �ti4-L L f/i+t-+YL
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
6 Irl
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 AGENf'OR CONT14 CTOR 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
as Ow r/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to t o
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Own r/ Date
• A
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:
a
I of Northampton
u u ing Department = .
Main Street
,�L 3 2042 oom 100
No tha pton, MA 01060
S587- 240 Fax 413-587-1272 io Ite.
D F{0 U er�Spt=t;l:
ICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be Com let' d b` tc
1.1 Property Address: P Y
- A)O. Map Lots E *, .
ZoneOuerlay DistrtCt' .
z..
Elm St District CB Dist"rct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1!Owner of Record:
rS e-r-c E-1—M4AIA sue` �t.b- �1i9�•� S/ /`- at-e ms
Name(Print) Current Mailing Address:
Telephone
elephone
2.2 Authorized Agent:
C 1A 64-J
Name(Pri t) Current Mailing Address:
S ure 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) s2� ,j,� ' Check Number
This Section For Official Use Only
Building Permit Number: Datelssued:
Signature:
Building Comm issioner/Inspector'of Buildings Date
BP-2003-0072
GIS#: COMMONWEALTH OF MASSACHUSETTS
.a I CITY OF NORTHAMPTON
AM
Lot:-001
Peru: BuildOg
Category: BUILDING PERMIT
Permit# BP-2003-0072
Project# JS-2003-0160
Est.Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group John Corbett 104000
Lot Size(sq.ft.): 23870.88 Owner: STEWARD ROBERT
Zoning_URB Applicant. John Corbett
AT. 58 NORTH MAIN ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:7123102 0:00:00
TOPERFORM THE FOLLOWING 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 7/23/02 0:00:00 1383 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo