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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AT, AAVIT
(lie�nseeJpermitiec)
with a principal place of business/residence at:
(phone,-H)
(st rc,--Ucity/stafeJzip)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following workers compensation coverage for my
employees wor6ng on this job:
(ma=ce Company) (Policy Number) (Expiration Date)
( ) 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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (IDSurancl� Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (1nsurdn.c-- Company/Policy Number) (Expiration Date)
(attadl additional shed ifntocmu to inc]udc information pertaiaing to all contractors)
O I am a sale proprietor and have no one working for me.
�I am a home owner performing all the work myself.
NOTE:pteasc be aware that while hancovnxn wtro employ pGrons to clo=iutrnance,arrs:rudioe or repair work an a dwcll g of
not mode than thme units in winch the hoal�owvcc rrsides or oa the ground.:appurtenant th c;c n ere cot gmcmIly oocsidacd to be
curployaa 11 the swrk&:s pompcm4on Art(GL152,ss 1(5)),application by a hancowvcr for a 6ccasc cc permd may evidcnoc tbo
legal darns of an emptoyec under ttsa Wocicces Compootaiion Act
I undasttad the x copy of this ctatcmmt may ba for Awdod to tbo Dctxirtmcni of In&L-it ial Accident,'Oflioo of laves 00 for tha
coverage vaificalion and that failure to acatre coverngo uudcr section 23A of MCIL 152 can lead to the imposition of criminal pcnali:ca
oomitiiz of a fine of up to S1,500-00 andloe anpt-isonmclit of up to one year and civil penalties in the form of a stop Work Or&-and a
finc of S 100.00 a clay against me-,
/ Foc&P�use o°ly
/ Permit Number
iviapil Lot#
S ttxre of Li erniittee 2
Wiz_.: - -- —
SECT�ON.B CONSTRUCTIQNySERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� iettet
RE
eil�Hbinurovem�ieTCantrK Not Applicable ❑
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 affidE
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)famili,
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act,
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
you hire to perform work for you under this permit.
The undersigned"homeowner"certifie and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, Stat n oc g Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
f ,_ a ds 3 �� w a ,,! '• r �� r
SECTION S ODE CRIPTION Q—J O, POSEDlWOR check all a licable
3.x,A.vaa v.,A'+ 3.... A 3 ....i4?'R xU dx s,a;, 3 krR:e.x. : ,,.,a.;_._,rq.>.�3,.,,.�#a'e�..�a.i:A51339NS3,...FAr.A'riUri. 3.,llaa, tl+lu.m1.3•� ....•. -
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ blew Signs [ ] Deck [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6 If Ne o se3add U2 ition fo a ci'sting lions°ing compiefe th o1roghr' :
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
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 7e OWNER AUTHORIZATION TO BE COMPLETED WHEN QWNERS';gGEN7 OR CONT1tACT.ORA
PPLIES OR: UILOING.PERMIT
as Owner of the subject grope,
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Print Name
Signature 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 lZ
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:
5
f Northampton
jui Department
ain Street
b;, Q1 r, om 100
4� ~ '� "L�Jor ton, MA 01060
e 413: 87- 240 Fax 413-587-1272 PIotlSite
DEPT OF S Q ING IN�PE � 4
NORrtR��10 CTtONS Ot erSpec�fy �'
.�. . � :
APPLICATION TO t O , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 3. - SITE INFORMATION '
This section to becom"Itetl I%.'` offtce,.
1.1 Property Address: u �
/ Ma Lot s W
f1 Zo �� p �
� y
Zone =' Oyerlayb]sct
�
� s
Elm'St. District CB: strict"" '
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Current Mailing Address:
Telephone
S 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
m leted by ermit applicant
1. Building Uo (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'lssued:
Signature:
Building Commissioner/Inspector of Buildings Date
B1I'1'R1) BP-2002-0378
GIs#: COMMONWEALTH OF MASSACHUSETTS
;6, k:36- 158 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Category:roofin g BUILDING PERMIT
Permit# BP-2002-0378
Project# JS-2002-0570
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sg. ft.): 11630.52 Owner: ELLIOTT CHRISTOPER L
Zoning: SR Applicant. ELLIOTT CHRISTOPER L
AT: 1 120 BURTS PIT RD
Applicant Address: Phone: Insurance:
1120 BURTS PIT RD (413) 587-3144 (�
FLORENCEMA01062 ISSUED ON.10/4/01 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/4/010:00:00 1037 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo