36-301 (2) j of Wart lttulpton
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
Square /Footage Amount
Basement @ .10 �/ �r O
1st Floor @ .40
2nd Floor @ .20 &3•�
1/2 Floors, Attic, Garage .10
Deck, Porches .10j
TOTAL
•- r O�`���pTO
°9 (UtL D itZ1 11t 7 DI1
$ 6 �Tasasciittsrtta,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpennittee)
with a principal place of business/residence at:
L v4 MA (phone#) W3'Z6c9 02
(streeUcity/statrlap) e9 t03 z-
do hereby certify, under the pains and penalties of pedury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
I am a sole proprietor, general contractor or homeowner(circle one) and have hired
e ontractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
f' iration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Exp
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shad ifnoocnary to include information pertaining to all ooatradors)
I am a sole proprietor and have no one working for me.
I'am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pasocss to do maiidenancS conshvdion or repair world on a dwelling of
not more than throe units in which the homeowner rides or on the grounds appArtenwd thereto are cot generally 000sidered to be
employers under the v4d ce'a compensation Act(GL152,ss 1(5))�application by a homeowner for a license or permit may-id—tho
legal status of an employer under the Worker's compensation Acs_
I understand that a copy of this statement may ba foswardad to the Departm of of Industrial A=dm&Offioe of imwraow for the
coverage verification and that failure to seem coverage under section 25A of MGL 152 can lead to the imposkion of criminal penalties
oonsistiag of a fine of up to$1,500.00 and/or imprisormt nt of up to one year and civil peaslties in the form of a Stop Wodc Order and a
fine of 5100.00 a day against the
For dgnatmeaw use only
Permit Number
Map# Lot#
Signature of LicrosedPermittce
S CT[ON 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: / Not Applicable ❑ f
Name of License Holder: C (N 4Q-L J-'g Wtb ® cl q l 1
License Nu •ber
PO -7 t 0:�Ad
dre Expirati Date
7 / � - �� � �
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTI0 1 10-WORKERS'CQMPENSATI ON,IN t1RANCE AFFIDAVIT(M.G.L.+x.152,§25C(q))
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.
igned 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
New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other( ]
Brief Description of Proposed Work: Zq13 11 CAPE W +LA taQ4oietv-4,
Alteration of existing bedroom Yes No Adding new bedroom 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: &°(dumber of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions . 3q
e. Number of stories? 2-
f. Method of heating? 6yks r F' 14 U) Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
' Type of construction C A 0 Jk 12
i. Is construction within 100 ft. of wetlands? Yes ✓ No. Is construction within 100 yr. floodplain Yes No
I
j. Depth of basement or cellar floor below finished grade Ll "(as fi —
k. Will building conform to the Building and Zoning regulations? V�Yes No .
I. Septic Tank City Sewer Private well City water Supply.
ECTN 7a -OWNER AUTHC?RIZA'f10N •TO ICEOMPLETFD WHEN
(1NRS AGEN ";O>l2 QNTItA! OR AN?pLt S F1 'BUI#.pING PERMIT
as Owner of the subject property
hereby aut ize VL C, 0A to act on
my behalf, i all matters relative to work authorized by this building permit application.
Signature of Owner Date
CAR at€.,,S 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.
igned 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 30, PS-0
Frontage 1, ! Z 5
Setbacks Front
Side L: R: L: R: Z? I 0
Rear 106 +
Building Height o ^'�
Bldg.Square Footage % G-
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: -T
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:
�D U /`P 4 I-/e"
0N'1- VO T9/� i fAIE
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587.1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1-SITE INFORMATION
1.1 Property Address: h " " ,
� .y +� r ry�� � z- t w 'mil C r�'p'/ a�/�j
k
s' �
SECTI ?N;2 PRI�PII:RTY"fWNISHIP/AUHtJRIED AGEMT
2.1 Owner of Record: �+ 1
Na (Pri Current Maili Addre
�it -_� � ` � �z
Telephone
Sign ture
2.2 Authorized Agent:
Name(Print) Current Mailing Address: C) t(j32 -07!6
Signature Telephone
��3-�ESTIIVIATED'�OI�STRI��TION COSTS.
Item Estimated Cost(Dollars)to be Ofllciel 4Jse,only '.
com leted b ermit a licant
1. Building �� (a) Building Permit Fee
L
2. Electrical L (b) Estimated Total Cost of
o R ()� Constructionfrom" 6
3. Plumbing -�7 °� Bullding"Permit F
l �✓
4. Mechanical (HVAC)
5. Fire Protection c LO
6. Total =(1 +2 + 3 +4 + 5) Check Number
�`hs Section For Offlcial Usk Onl
Building Permit'Number: Date Issued:
Sgrlatur � �_ � �_
Eui ldi ng;.Comm�ssionerll nseor zif`'Bu�I � g " Date"