11C-008 ��1W-f p�,
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a � °ti 6iIT, of Northampton
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DEPARTMENT OP BUILDING INSPECTIONS 4
212 Main Strcct • Municipal Building :c'
Northampton, Mass. 01060 UII•.
WORICT,R'S CONIPENSAT1ON tNSURANCE AFFIDAVIT
//fit)/^-5 I, At G"--'
(liccuscclperrnittcc)
with a principal place of business/residence at:
1/ t%r-t Aciti S Aint-1 p cT? r1- (phone)6-A4 64/4
(srccici ty/soatdn p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's comncnsaoon coverage for my .
employees working on this job.
(Insumor Comr n\') (Policy Number) (r,-plruon Date)
.
(1) I am a sole proprietor, general conu actor ye homeowner roe one) aid have hired
the contractors listed below who have the foUo\ I• -•. '-e s compensation policies:
HAM-)442 C ire .i Ai 78 ?'4, r Il e,31 o_
(Nnmc of Conractor) (Insurance Company/Pout; Nunn r) (t_xpirouon Date)
(Name of Contactor) (Insurance CompanyfPo!icv N'wmcer) (Expiration Dale)
(Name of Contractor) (Insurancz Company/Polic-y t•umbe.r) (Expiraoo Date)
(Name of Contractor) (Insurancu Compaay/Policy Numbs) Expiation Date)
(anad),rt'lioocal tbcct tf nccczary to ordudr infocnaaoa peruaamg to.L ooac-orr)
6 I am a sole proprietor and have no one worldog for me.
( ) I am.a home owner performing all the work myself,
NOTE:plc-t<be.wart thx:wt,-.3c Ixmrrn+vcra wbo cazplay f).---sons to do r^ ,•-, ,a� cam-,-c-1oa r_ tc,xu work on.(1...-I1.1g of
not mote thn t =i',in«$ich the bocnoowncr raid=oc oo the p-=a=ril appurtcnsm tb.rto c.-c w cc),---ally oec,:do to be
ca-ploycn une,c-ttx,•Q"-k121'1 cticr pct(GLl52 rr I(5)),npplir,rion by n botncow-ccr for:lip__or L=oan rney cvidcocc llx
legal ctanrc of nn foyer wader(LID Worircic Coenpc iioa Act
I undcrstxod that a,Dopy of chi,cxatcmmt may bo foa-worded to tbo Dcgnrt'-s=t of I trrid Am4 cr OfLoo of lnr+asooe for the
coverage vcriftcztioa and that L-iltrc to cowry'covn- c under section 25A of MOL 152 can Icad to the i ica of criminal pcnzlli°
000aining of R floc of top to S 1000.00.=Not iraprisow c g of up to one ye-or nod civil pmxlUo in t`Sr form of n Stop Work Order end.
lino o(5100.00 a day L ainat 0x
For acp.rtat>=col■.c oaly
Alii/ Permit Number
i,4,44----- 2f-ed M a __ Lot Signature a nscrlPcrraiuce Date _ ..• __ ...
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /46 //'/ /4112-7iZ
License Number
// L A A)AGH " S' I 11 -4- C/Z y/6 i
Addre Expiration Date
`r s&q 4/4
Signature Telephone
,1 - .1�� E1 � .. � an $ . ., °. : ' Not Applicable ❑
Company Name Registration Number
/! /rid /
Address Expiration Date
Telephone 6 &414
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 ig('
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 a Loca oning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature /O7 144-'L-
SECTION 5- D5SGRlPTIO OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Ar
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding p()Q Other [ ]
Brief Description of Proposed Work: /.Jj w CYar *
Alteration of existing bedroom Yes jC No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes tc No
Plans Attached Roll ❑ - 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?
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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
6uA1 A• t,7-_ , as Owner of the subject property
hereby authorize 6 ' ' r- to act on
my beha f in all matters relative to work authorized by this building permit application.
Signa ure of Own r Date
Xit.)/✓u �� — , 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.
rt-i/k-ifA`1'F,6'
Print N e
A407/7/7 L2
Signature of O ner/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
8(.> r
Lot Size y (co
Frontage 56
Setbacks Front
Z J
Side L: R: 11,
L: R:
J
Rear i 7
Building Height Li t
Bldg. Square Footage IN
Open Space Footage
(Lot area minus bldg&paved O
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 x
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:
Y•'•
Department use.only
City of Northampton Status of Permit. - : ' '
Building Department Curb Cut/Driveway'Permit
212 Main Street Sewer/Septic AVailability
Room 100 Water/Well Availability ,
Northampton, MA 01060 Two Sets of Structural Plans_ , - `
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
1 bri2 'H-,� Map . Lot Unit
i / Lb' � rio-o/ rp-6\i 444 Zone Overlay District
E ,St. District CB District__
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr Current Mailing Address:
,- 81 6411
?✓4411I b,� Telephone
Signatu e
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 permit applicant
1. Building 0,Cad (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
11 BERNACHE ST BP-2001-0334
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-008 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:ROOFING/SIDING BUILDING PERMIT
Permit# BP-2001-0334
Project# JS-2001-0547
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 7971 .48 Owner: AYER KEVIN
Zoning:URA Applicant: AYER KEVIN
AT: 11 BERNACHE ST
Applicant Address: Phone: Insurance:
11 BERNACHE ST (413) 584-6414 0
LEEDSMA01 053 ISSUED ON:9/28/00 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL NEW ROOF & SIDING
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 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo