32C-123 (6) B�0 4e (rxt�l Jaf &NO t1julllptoll
aBrsanrhnsrtta
m DEPARTMENT OF BUILDrNG INSPE'CT'IONS
212 Main Street ' Municipal Building -
Northampton, Mass. 01060
W0RYCER'S COM ENSA'ITION INSUR.-A-NCE ATTAMAVYr
(li�ns�c/pernv ttec)
with a principal place of busuless/residence at.
_ AJ
(str�:1J c i ty/naie/zi p)
do hereby certify, under the pains and penalties of perjury,
O I am an employer providing the followim, wor} er s cotnpensat,101-1 coverage for my
employees worldrlg on this job-.
aas-usance Company) (Policy Nuzihx-r) (Expiration Daze)
( ) I arri a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers coi- pensa�OFI policies:
(Name of Contractor) (Insurance Company/Poticy Nu-rnl--r) (Expiration Date)
(Name of Contractor) (Laauancc Como anv/PoIicy Number) (Expiration Date)
(Name of Contractor) (Expiration Date)
-- (Name of Contractor) (Insurance,Cornl ny/Policy (H-xpi-ation Da(c)
(anacdt A&Jit Cc JA z xct ifncccnATN to ixludc iafoanition pertain tr,all
l
O mii a sole proprietor and have no one for Cie.
I am a home owner performing all the wort, myself.
NOTE:ptesae be aware ttut tNb lc -,--play pc-,—Om to di c a tray c ar:- r c Gr repa Lr WWk on s dN,cIling of
riot m ce than three units in wt-ndt the honboancr reside ct oa Qu E oputte: rl lhado -r rxt C,:� ilIy oxiducd to be
c^tployca under the tvarku s oaz tticn Act(GL152 i(S)�,arpl:A ice bye hcTnzouzrs for a{;c rc x p r n t nuY cv daxx the
legit aR us of an employer under the Workres Compcnlslion A.,d_
I understand tlut a copy of this etat.cmcut m.y be famamtod to the Dctxiitnrar2 of lc>di t iel A"vi—�Y Ofriao of LII iDCe for tlm
covaa�vetiFication and that failure to actirrr coveragO undx scelion 25A of htQl,152 can lr.d to the intpositiort of czicim-tl penalties
a fux of up to S 1.500.60 arwor unprisoaax of up to cqc}car and Civil prnnitin in dx f-M of a stop Work Ord-and a
fen 5 GO a ds siu uY
Foe deps tnwC'1 u,o arly
j2 �� Permit Numtxs
rp;t _Lot#
j Sipklture of Liom er iucc
_�,,{]yy.Y-Ft
ESQ d �c,l:�:__.,. "'—._ .. I
SECTION 8-,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ` C "�-'�- Z - `� "k � 7 C - 5— 7c,
License Number
U
Addres / Expiration Date
Signature Telephone
r9 Re istered,Htimelim r. vemen _
N ot Applicable El
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...... ❑
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 buildiny. 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 fer 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 yo in this permit.
The undersigned "homeow s and a�StTrrtesr� }antlsib�i y for compliance with the State Building Code,City of
Northampton Ordinances, at oc _onino a� 'ta " .Massachusetts General Laws Annotated.
r
Homeowner Signatur
SECTION 5-!.DESCRIPTION QF PROPOSED WORK(check;Ol aaalicaWe)
New House ❑ Addition ❑ Replacement Windows [Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: LJ E)c'os'y
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a 'IfrIN ho"use.and:0 .ad iition-to-"6XWhz' ou"sing,h:complete.the g followin :
a. Use of building : One Family-c 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
_ as Owner of the subject property
hereby authorize _ _ to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
`C ff �Z- �' _ as Owner/Authorized Agent
hereby declare that the statements and information on thi foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
� — Z)() —/--z —
Print N m
nature 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
I
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 frorn 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:
City of Northampton Sf F? F
Building,Department Curb>Cut/D=, e
212 Main Street SeweSep_�c
I.
Room 100 Wa erlWeti
r
Northampton, MA 01060 TwoSetso Str c an
ph'oSe 413" -58'7-1240 Fax 413-587-1272 PI t/SitePlaris�
Other Specify
7
-_ �. _ .. . : s.�._
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
Z j t��-(�( ! Map Lot Unit
\1�l`t Zone_ Overlay.District
(J Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �^
Name(Pr� Current Mali ng Address
- — — � 7 Z � �---- --
_ _ Telephone
Si ature
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) __Aimated 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: _—
I Building Commissioner/Inspector of Buildings Date
28 FRUIT ST BP-2003-0565
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 123 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate orv: BUILDING PERMIT
Permit# BP-2003-0565
Project# JS-2003-0928
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 5401.44 Owner: DOHERTY MICHAEL J&
Zonin :Ug RC_ Applicant: DOHERTY MICHAEL J &
AT. 28 FRUIT ST
APPUcant Address: Phone: Insurance:
28 FRUIT ST
NORTHAMPTONMA01060 ISSUED ON:12110102 0:00:00
TO PERFORM THE FOLLOWING WORK:I N STALL WOO DSTOVE
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:Oik' /-3 e-T I V
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/10/02 0:00:00 1318 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo