32C-182 (13) OPWI
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c� DEPARTMEIJT OP BUILDING INSPECTIONS
212 Alain Street Municipal Buildint;
Northampton, Mass. 01060
WOR -R'S COMPENSA ON IN IIRANCF AF MAVIT
1, �-�� --------- _ 6 - � �--- -- -- -- -_ -
(1�ccusccJpertni flee)
«-ith a principal place of businesslreside cc at:
ft
-�
do hereby certify, under the pains and penalties of perjury, that u
( ) I am an employer providing the following worker's compensatlon coverage or my
employees worming on utis job.
(IILSLLr?nCr Corse nv) --- -- (Pohc-.Nu_mtxr)
;
( ) I am a sole proprietor, general contractor or homeowner (cLrcie one) and have hired
the contractors listed below who have the following worke s compensation policies:
(Name of Cont:ncro:) Coinpan),IPouc; Nmnbc:) Date)
--- (Name of Contractor) --- (Insuraacc Comoany/Policy NumL-�-.r) (LxvtF-,.ucn Date)
(Name of Conti-actor) (Insuranc: Company/Pokcy Numtxr) (Expimuon Date)
(Name of Contractor) (Ln_nuanoc CompaayfPolicy Number) (Expif,36on Date)
(auach addit:oaal:beet if ncc�r to inchrdr infocmvnoo pertaining to all oou7nCO a)
f f am a sole proprietor and have no one workdng for me.
( ) I am a home owner performing all the work myself.
NOTE:plr3e be awzrc the KArjo boa="-ocr3 who employ pcsom to do m.;T-te.,..,n ccasn:rioo cr rrpau d-. Ll g of
ux,c more thn throo units in which the Lwm<xA ncr resides or oa the grouar43 appurtc Lire thcctn zrc pot CcDcr21ly ooetidacd to be
caiploycn u3dcr the tvo;�o=pal-sLcKi Act(GL152-3 t(5)�application try a hotnco vocr far t liana or perm m-Y c 76cooc ttx
Ic-9xI ctatiu of an cmployor under dt Workcec Conapomat.ion As-
I understand dLe a copy of this rtztcmcat msy bo forw—i&d to tho Dcpntturat of Isidzi5tial Arod-o&Offioo of lo�for the
oovcrz vgtficnlioo and that f_iltn-c to scauc covc� under scctioa 25A of MOL 152 c3n lad to tba itrtpositioa-f aimin3l pcoaltia
eoaiuting of a fine of up to S 1}00.00 and/or il: pri3oom of up W one year Lod civil pros hum in the form of a Stop W ode Order and n
fim of S I M.00,,day■gtinst me
For&�I use o(-Ay
Pcruvt Numbcr
Side tore of Li ct-nutter,
r"
ts.1 Licensed Construction Su erv" Not Applicable ❑
Name of License Holder : /�
License Number
G
Address �.�. Expiration Date
Sig Lure hone 77 j7
Not Apl?/Ioicable ❑
Company Name Registration Nu 71er
7
Address Expiration D e
Telephone
SEGTIQNIQ�:VYQI� RS' .15
10 AFFIDAVIT:(m,G.L..c.:152,§2C(.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.
;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 108.3.51.
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
CTIQN,S <?I`S�� R[l�7laNQI`:PI�OPt�SEpF-1�fIR-[�4,(check ati a��licah(e�:
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: terra r`e�x�i//W7 , oo� 4ns57A�� ,5 `;�YC'` Sh'�1 �° p A
/
Alteration of existing bedroom Yes No Adding new edroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes 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?
.. 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 Ft3R BUILOING PERMIT
I, 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
I, /Authorized Age
hereby dec are that the statements and information on the foregoing application are true and accurate, to hest_c#- r�
knowledge and belief.
Signed un ins and penalties of p rjur ,
Print Nafie
-4/— A
Signature wner/Agent Date ,r,?
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:
Y.
C7', of Northampton
B ing Department
Main Street
oom 100
' -Northampton, MA 01062
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTON.1-SiGTE.1l�FOt�M�CT`ION'
s e�cs r W 1` + 'h �
1.1 Property Address: M
-N,u
SECT IT�..? P R,60ERT _Q;RIZED°=A
2.1 Owner of Record:
iiLc s--�-
Name(Print Curren Mailing Address.
p r� O
Telephone - Q CD
Signature
t
2.2 - ed A ent: 6noV le -e- (j IPA
Name(Pr' ) /—rrek Mailing Address: 3 (
Signature
SECTION 3- EST MATED.CONSTRUC:T:Ibf+t 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 Butt0k. iarmR Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 + 3 +4 + 5) Check'Number �"-
This Section For Official Use Only
BaJildingPermit Number. Date Issued
Slgna��e:
wilding:Cornmissionerflnspecto of Buildings Rate,
376 PLEASANT ST BP-2000-1081
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 182 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1081
Project# JS-2000-1933
Est.Cost: $2335.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 7361 .64 Owner: SZLOSEK STEFFIE&PATRICK&
Zoning:GB Applicant: Robert Thibodo
AT. 376 PLEASANT ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON.611100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE TO REAR SHED EXTENSION
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 6/1/00 0:00:00 7060 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo