25C-056 z� °ti (rif ) of Torfl alit foil
U Q
DEPARTMENT QP BUILDIIG INSPECTIONS
212 Alain Street Municipal Building;
Northampton, Mass. 01060
WORICTR'S CONUENSATIO INSURANCE AFTIMAVIT
(li ceuscrJpcnni f tcc)
xvith a principal place of business/residei at:
1!��Xphone
stTc tdcjiy/Sta1CJnp)
do hereby certify, under the pains and penalties of perjury, thr
( ) I am an employer providing the iollowirw worker's colnpensanon cove Se 'or Inv
etuployees vvork�ng on tills job
(Insrance Corp ny) -- — (Polio.Nufuir_r) ---- - (E�.
u I ation Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contt:ic*,o-) (Iii--L ancc Coinoany/Pobc-1 NumLcr) (Fxpirduou Date)
(Name of Contractor) (Expirition Date)
(Name of Contra(nor) (Insuranc Company/PoLc} Ntunbu) (E\pimnon Date)
(Name of Contractor) (Insurance Company/Pot cy Number) (Expimuon Date)
(arli h additioal sbxc ifn�}to mcluc�iafoiuu:ioa pcztain rig to all oaatm o. )
�a sole proprietor and have no one workdng for me.
( ) I am a home owner performing all the work myself.
NOTE:plrsc be await th[i wt>;lo hoa>cowocn wbo cusplay pe, m to do m T^ mrn:rvr..ioo cr>tpau work on c d.%clling of
not morn than throc tm113 to w6ich the botu�rrsidcj oc oa the Uourdi apputcnun the ct ate oo(gcacrtalty cocnlckr d w be
employcn under the wcvz c oDaip oa Act(GLI52�s l(5)�n4VLi abw by a homcoavcr for e lirux cc permii may cvr6cna the
legal clut—of en amployoc under dro Wofkca t Con ooastioo Act
I underrt..,nd tbLe a oopy of thix�s y bo foczvnrcied to tho Dcpact---d of lndusriel Ac dcots'Oftioo of Ic—for Um
covcrtgc vrri c3iioc and thu L•ilurc to acatrc covcT under soction 25A cf?,(GL 152 can Imd to tho-4-bO13 of criminal pcnattics
cooaistuig of a fine of up to S 1,500.00 endlar cnprLIOUnc11 of up to ooc year end Civil pcnnhio in d)c form of a Stop Work Order and a
rim o(SIWDO [gainAme
For dcpxrurc--il use only
Pcruvt number ----
G'd Lot r
Si lure of LicetiseeJPctztuuee ---- -e
`CTiQN�-..��i�1S'�'RUG'Ft+�N:SER1tit�ES
a.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
A�,erl-��,
Address Expirati Date
Signature, Tel one
kb.. 3. ..".= Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SMCTIDl .1Q-:WQRIfER V':COMPENSAT10h IN'SUgANCE AFFID"IT(M.G.L.,c:152,§250(4,))'
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 108.3.5.1.
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
CTIOIV S I7SCRIPTIOt�F OF tRERQSjD.1�i01t4_ h�sck att:appticahte}'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
va
Alteration of existing bedroom Yes No Adding ne 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 un' : 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
G f
f �- ✓z� -(i e Authorized A e
hereby declare that the stateentsand information on the foregoing application are true and a urate, to t e best o my
knowledge and belief.
Signed under 'ns and penalties o erj
D c V0
Print Name
Signature of A ent Date
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:
d v f Northampton
B ng Department
Q 2 6 Main Street
!�� •- S R om 100
ton, MA 01062
f bho 87-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-Slm t t 1 SI''it[NI f E iiAATION
"i"tlis' �11 tO Icor
1.1 Property Address: �Y
y
SECTIiC I±I.2.:-PFRf?PERTY W(�ERSHI-RIAUTHi�RI�ED.A,G=N"T
2.1 Owner of Record:
37
Name Pnn Current Mailing Address:
Telephone
SignatLNe
2.2 Authorized Agent:
01;4-4
Name(P ' Current Mailing Address:7e-1
Signatur Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS ` -
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Bui Idingz Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction fr6rri 6),
3. Plumbing Building Perfnil:Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) Check..Number
This Section For Official Use Onl-
Building Permit Number: Date Issued:
Signature:_
Building Commission
p jnspector of BUHdings Date;
t
37 LINCOLN AVE BP-2000-1080
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mgp:Block:25C-056 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofin BUILDING PERMIT
Permit# BP-2000-1080
Protect# JS-2000-1930
Est.Cost: $2435.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 12980.88 Owner: SARRAZIN GERALD R&ROSEMARY B
Zoning URB Applicant. Robert Thibodo
AT. 37 LINCOLN AVE
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 ROOF
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