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m DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFMAM
IP41 17
(li�nserlpemiiucc�- - - ------
with a principal place of busuiess/residence at:
ee
(streetici ty/statrJn p)
do hereby certify, under the pains and penalties of pefTlry, that:
(pl< an employer providing the following v,,Ovker's compensation coverage for my
employees working on this job:
/7.��r _ l✓ G �G b�-y_7_-off'---- � 6
611 Cc Company) (Policy Number) (hxpimt on Date)
( ) I am a sole proprietor, general contractor or homeowner (circle on(;) and Have hired
the contractors listed below who have the follo,ving worker's compensation policies,
(Name of Contractor) (Lnsuranc-- Company'Poticy Number) (Expiation Date)
(Name of Contractor) (Insurance Comnany/Poticy Number) (Expiration Date)
— (Nam(-, of Contractor) -(InsZU,nic,� CornpanviTolicy Numl-xr)-- (Expiaation Date)
(Name of Contractor) -^ (Insurance Coni XLIIy/Policy Number) (Expiation Date)
(s[tadi ad'litioail:?fcci if ncrc�vr:to irxludc iarorma:i on pertaining�all axe`-rn dCin)
O I am a sole proprietor and have nc one -vorking for me.
( ) I am a home owner performing all the work myself.
NOTE:please be asvarc tt�whi]c hancaw�xra tvho cmploy P=C-z to w m�iatcaancc�cc rIn teen cr repair�Nulk cn a d«dling of
ncX meet than throe units in wtrch the I, r, uvcr aides a oa the g-,X4,� appurtcnuil ihaQn uc rxt Fat Iy omsu1::cd to be
ealployc13 uadtr the tvorkC s axz station Act(GL152--z 1(5)),a{pli:aiien by a homcowvcr for a licaise cr permit n,-tY nitkncc the
Icga1
"Us of an employer under the Wocicc<'e C Mpanaktion Ad_
1 underhand that a copy of this or tcm may bo forwnri«1 to th»p,Ixi t. d of Indiutrid Aa 6-Ai'OfIioo of Iir�—for tha
oovezt vaiacatioc and that failure to!,aim oovefngo under section 25A cf htGi,152 can Icad to the imposition of a moral prnalt d
oomutin of a fine of up to S 1,500.00 tulSor ilnpriSpma1C t of up to one)--r rn1 civil pcsultia in d4 form of a Step W crk Ord-and a
fine of S t W.0(1 a day>pinsi r r
Foe dVart Ifll uao only
permit Number
�� Nfatr'l Lot I,
tgkaturc of Licctlscc/Pcrmittct; 4
t
SECTION t-„CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder D G2 �
License Number
Address Expirat n Dat
Signa re Telephone
u } Z i e it a
Re i tered�E�orneJm r. uemerC"n ractor; �� i�' t Not Applicable ❑
Company Name Registration Number
Address T Expirat on Erate
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...... ❑
` . � kOm 10, near empt n`
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 riot 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
SECTION 3-:DESCRIPTION OF`PROPOSED WORK(check all applicable)
. _ pp ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks rr[ ]] �Sidiinng[ ] 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❑
5a:1f Newhouse` Wnd 6KF dd itidr to existing;- housing,°::co'MpletbAhb,,J611Wi j7:
a. Use of building : One Family Two Family_ Other
b. Number of rooms in each famliy 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 AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize 9011/ �i� i ti lI�`�s�e .,Z';,• _ to ac*, on
my behalf, in ters rel tive to work authorized by this building permit pplication.
Si e of Owner Date �J
I, `t•/�G /Gli � �� �going __ as 0 er/Aut horzed �Igenl hereby declare that the statements and informaton on lication are true and accurate, s o
knowledge and belief.
Signed under the/gins and penalties of perjury.
Print Na
Qv _
Signature o wner/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
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW el� 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 y_
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:
City of Northampton
b -
Building Department
212 Main Street
Room 100 Wa r Well t
Northampton, MA 01060 Tw �� s4o
phone 413-587-1240 Fax 413-587-1272 Pk It Plan # X.
Otf er Sp,t�tf 3
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Propert�Address: This section to be-completed by office
Map Lot- Urit
w 77''cc E
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print � ��rrent �.Iaihng _La�`y�
� — — _ Telephone
Sig at
2_2_Authorized Agent:
kv
Name (Pri Current Mai!rng Address:
Signature Telephone
CSECTION 3 - ESTIMATED CONSTRUCTION COSTS
lien). Estimated Cost (Dollars) ;e be Official Use Only
completed by_permit a,r2, hcant�
1. Building (a) Building Permit Fee
l
2 Elec�rical (b) ::.timated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
�d- Mechanical (HVAC) _ - -/
5. Fire Protection
6. Flo tal =_ (1 + 2 + 3 + 4 + 5) �� --_– CieckNumber — _----
This Section For Official Use Only _
Building Permit Number: Date Issued:
Signature: — - --- ---- ------
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0094
APPLICANT/CONTACT PERSON PHIL BEAULIEU&SON HOME IMPROVEMENT
ADDRESS/PHONE 217 Grattan St CHICOPEE (413)592-1498
PROPERTY LOCATION 44 WINTERBERRY LN
MAP 36 PARCEL 229 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
FeA Paid
u'1 'n Permit Filled out
ee Paid
Typeof Construction: Strip and reroof
New Construction
— Non Structural interior renovations
Addition to Existing
—_ Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Perniit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
— 7/-& L s,
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2009-0094
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.6 i" =i2i CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0094
Project# JS-2009-000123
Est. Cost: $8250.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PHIL BEAULIEU & SON HOME IMPROVEMENT_
Lot Size(sq. ft.): 104544.00 Owner: MINNICK TERRY J&LISA L
Zoning: SR Applicant: PHIL BEAULIEU & SON HOME IMPROVEMENT
AT. 44 WINTERBERRY LN
Applicant Address: Phone: Insurance:
217 Grattan St (413) 592-1498
CHICOPEEMA01020 ISSUED ON.712412008 0:00:00
TO PERFORM THE FOLLOWING WORK.-Strip and reroof
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:
FeeType: Date Paid: Amount:
Building 7/24/2008 0:00:00 $35.003814
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo