36-014 (4) Y
2- L ---
F E (rift) elfInz #11a11t�tn)I _—
DEPARTMENT OP BUILDING INSPECTIONS —
212 Alain Street ' Municipal Building;
Northampton, Mass. 01060
WORIQ,R'S COMPENSATIO EN U-1 NCE AFFmANII'
(li ccnserJperrrli ttcc)
\vIth a principal place of business/residence at:
(;hone--) -- - 7�� �f'?75
�7rtit/c�ty/stalc�zi p)
do hereby certify, under the pains and penalties of perjury, tf}lat
( ) I am an employer providil the following worker's comucnsanon coverage for lnv
eluplovees woliang on tills job.
(Insuiznc�: Comp ,Cy) (Polio Nu_,lbcr) (Lxpir uon Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) a-nd have hired
the contractors listed below who h2ve the iollo%ving worker`s compensation pchcles:
(Name of Cone.-:ctor) (Iiisur-ancc Compare}'/Pcuc; Numb--:)
—(Name of Con[Tacior) -- (Insurance CompaDwTolicy (Ex p ation Date)
(Name of Coarncior) (Insurance Company/PoLic)• Number) -- (Expu-3uon Date)
(Name of Contractor) (Insurance Compaoy/Pohcy Number) (E\piration Date)
(aaach additioail 'vxei if aocaz�to inc!uck infor�uli oo pertaining to ell ooa7m�.on)
am a sole proprietor and have no one woridng for me.
( ) I am a home owner performing all the work myself.
NOTE:ple-sc be-w-j-m die,wtr:lc hourouven wbo employ pcsom w do r. az r on cs rep-aa wort on e d-rlLng of
not atocc then tbruo unit+to wtndt the bamoown r r c dc3 a oc the grounds appurt<nsLd Ih-do arc oo(Ecn-2y O—idcrrd to be
claTloycn under the tvcxi:u'z o=pcsation Ad(GLI52-s31(5)�a4ptira6ou by a homnowocr for e bcm--e cc po-mA may evidence the
lcgil ctnmrs of an znployoc under dw Work j&Compemaiioa Act
I unZas d dirt a copy of this cht—I mny bo foc ,uxied to tbo D"xtro o2 of lo.&,,trial Au d—&Ofnoo of t—for lfm
eovcrxb-c Val6cslioc mad th t f_lure to acaxt oov,r under soetioa 25A of MOL 152 can Icad to tbo imposAioa of mmiuil Pcmttia
eoa3iniztg of a ripe of up to S 1,500.00 and/or of up to ooc year end aril pcnahia in dx focm of m Stop Work Order and a
fish OC S100.00 i day igauul OY-
For dcpulm-�uic only
Lot n
St�1 of LiccsiscrlPCMIWce ---- e
r
1"C7'!QN`8 Cf7NSTl�UCT113W S1=Rl�I,Clrs
a.1 Licensed Construction Su ervi Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature T ephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTIC3N 10- # ERS'±�MPEb1S' !61411'INS,RANCE AF.,F1DAYIT(M.G.L..c.162, 250(�}�
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.
fined 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
CTION 5 DESCRIPTION OF'PRQM'CD WORK(check aff applicahW,,
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ 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 Nom
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
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
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, 1 horized Agent
hereby declare ha the statements and infor anon on the foregoing application are true and accurate, to -best of-aay-
knowledge and belief.
Signed unde p i sand penaltie a jury
Print Na
Signature of Owner/Agent D e
i
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:
��Q [ of Northampton
D ing Department
2 6 2 Main Street
oom 100
a pton, MA 01062
DEPT t)I<SU . `� � � " 3 2.1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT, .l..-SITE tRFORMAXIION ye p y� ¢y (♦/,(�
.. Thisse�rr dto I1ertic�ft+sflAl?y�'o v P
1.1 Property Address: :� 3 ;
p�
/
��
.
SEC'[I X1:2'-P PERTY 0W9"ME7SHIPIALITHORliZEC6'AGENT
2.1 Owner of Record:I 1 /
A;� 3 w� le..
Name(Print)—N Current Mailing Address:
tivv� Telephone
Signature
2.2 Authorized A=U,
2 h
Name(Print) Current Mailing Address: 0�3�
Signature Telephone
SECON 3 -'ESTEMATED ST
CONRUC.T,IQN COSTS
TI
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 Buit fiig Permit Fes
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4+ 5) Check Number O
Thin Section For Official Use Only
Building Permit Number: P02 Date Issued:
're;:
6uitding nspector af'BUH..dings Date
Gocnmisstaner�l
"47 FOREST GLEN DR BP-2000-1078
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-014 CITY OF NORTHAMPTON
ot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-1078
Project# JS-2000-1927
Est.Cost:$1685.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 13982.76 Owner. KIMBALL SHIRLEY A&DEANNE R
Zoning URA Applicant. Robert Thibodo
AT. 47 FOREST GLEN DR
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTONMA01061 ISSUED ON.6 1I 100 0:00:00
TOPERFORM THE FOLLOWING WORK.-INSTALL 1 PLY RUBBER ROOF ON
BREEZEWAY/GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
�derground: Service: Meter:
Footings:
ugh: Rough: House# Foundation:
"al: Final:
r
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 Tyne: 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