25C-239 Y
o4.ST0
8 6 �assxciinsctta'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060 �" s
WORKER'S COMPENSATTONVINSURANCE AFFIDA.VTT
(ltcenserlpermittee}
with a principal place of business/residence at:
2-0-7 Q-4.1c 54. ; No-t"r)o1 /'rA 014o (phone#)_ 113 c)1-77
2
(sftr-Wcity/staW p)
do hereby certify, under the pains and penalties of perjury, that:
kill'
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
f; (Insurance 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/Potrcy Number) (Expiration Date)
(Name of Contractor) (Insurance Compam/Poucy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sbect if n6oe=ry to iacbKle infocmaaon pertaining to all oo trvdon)
O I am a sole proprietor and have no one working for me.
( am a home owner performing all the work myself.
NOTE:please be aware that whilo homeowners who employ pc=m to do m&bAm_.&W'conSnidion or rgmir work on a dwellmg of
not moc'o than throe units in which the homeowner insides or on tSe grounds appurtenant thxde are not gcousAy ocaridered to be
employsa under the wnckees cornpcawaioa Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may evidence the
legal status of sn emQloyec under die Wmkela Compensation AcL
I uuderstaad that a copy ofthia statement may bo forwarded to tho Dcpartu m2 of Industrial Accidents'Ofoo of Iasvrsnaa for the
oovetagc vcrifiauion sad that failure to secure cowmso under sectim 25A of MOL 152 can lead to the imposition of criminal pea Mc s
ooasbtiag of a die of up to S1,500.00 andlae im{ttrs0nm4%A of up to one year and civil pcaaltics in the form of a Stop Work Ord'-'and a
fm o(3100.00 a day againa ma.
For dgmtm�uao only
8 Z 1 Permit Number
Map# Lot#
Signature of Licenseelpermittee
�tC,TION S•CONSTRUCTION SERVICES' .
1 Licensed Construction Supervisor: Not Applicable W
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
N11 "Im
Not Y ...._.F....€" Applicable IRr
Company Name Registration Number
Address Expiration Date
Telephone
SECTlON:1Q°;WORKER$'COMPENSAT ON 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.
igned Affidavit Attached Yes....... ;I 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, Sta and Local Zon' Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature '~
j
PR
C! SCfglE1T,",0N
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition19 New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: e'al Wn otJ 44el 2_ I
aVn '4'' .1k w..k MySsl
Alteration of existing bedroom Yes o 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: 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
S 'I IQ I , pWNEIt UTHORI A71flN Td;BE CQMpLETTED WHEN
0 111"i5 AGI>*N7"Qh C{)IV712ACTO�t,aOF'IrIS IC1R BUILDING PI~RMiT
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
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.
r v a A 5�0"6
Print a e
;o 1 l4,vI
Signat re 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
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:
w
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�1NFORMATtON
,
1.1 Property Address: '
ko
ton uerla #riot
SECTION 2 PROP.,ERTY OWNERHFPIAUTHOFZEp AGENT
2.1 Owner of Record: C
Agr;c.%A 3fAtn j 2,o-7 �n�k� 4.
Name rint) Current M 'ling Address:
s 46-,0-1-1-7
Telep onhon e
t;ignatu e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
_E tfON S STIIC�FAK l3'CONS' RUCTIt N CQ TS
Item Estimated Cost(Dollars)to be Official Use Only
ccm^leted by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total'Cast of
Construction fromr !, ,
3. Plumbing Buil&ng Permit fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Check Number
Thus Section for Official Use Onl
Building Prmlt Number: 2F bate Issued:
BuiJtt#itti.Commissner/l nspectvr of P zildirip,
[late
BP-2001-0854
GIs# COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2001-0854
Project# JS-2001-1591
Est.Cost:$0.00
Fee:$10.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 16204.32 Owner: HENRY KARIN M&HOWARD DUPUIS
Zoning:URB Applicant. adrian staub
AT: 207 BRIDGE ST
Applicant Address: Phone: Insurance:
207 bridge st
NORTHAMPTONMAO1060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK.-DEMOLISH OLD SHED 20X15' NO UTILITIES
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 384 $10.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
,—�- — ��_ __ — _ __—_�__e ��._ ��,.�
�.
..� � ae
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.�.
207 BRIDGE ST BP-2001-0854
GIS#: COMMONWEALTH OF MASSACHUSETTS
MM:Block:25C-239 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate&M: BUILDING PERMIT
Permit# BP-2001-0854
Project# JS-2001-1591
Est.Cost:$0.00
Fee:$10.00 PERMISSION IS HEREBY GRANTED TO.
Const.Class: Contractor: License:
Use Group:
Lot S' sq.ft.): 16204.32 Owner: HENRY KARIN M&HOWARD DUPUIS
_ z, on;ng:URE! Ana�icant- adriaa ste ub
AT. 207 BRIDGE ST _
Applicant Address: Phone: Insurance:
207 bridge st
NORTHAMPTONMAO1060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:DEMOLISH OLD SHED 20X15' NO UTILITIES
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: 0/r d fo 03 � --
-
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occul2anc Signature:
Fee TV
ne: Receipt No: Date Paid: Check No Amount:
Building 384 $10.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo