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12C-052 (2) �ttwr�T Z0 Gvti3.c,0 -- R °E G1 of �'Tc tllanlptoli �la�.R(hncrtla _ _ DEPARTMEI T OP DUILDFNG INSPECTIONS � 212 Alain Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURA_.NCE A F ' AVIT (li ccascx/perrrri ttec) \,.rith a principal place of business/residence at: () hone') (SO-C.W61y/S12-tc ip) do hereby certifjr, under the pains and penalties of perjury, that ( ) I man employer providing the following worl<cr�s colnocnseL3on cove mge for m�' eluptovecs wor-Lang on 01is job. (Lnsur-;nc-_ Cocap ny) (Polio; Nunarr) ----- (r=xpiroon Dale) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the con7actors listed below who hive the following worker's comnen-,,ation policies (Name Oi C0:11:naor) (Irlsumncc Coinpan)'ii'oUc; Nucnbcr) (Y_\)lida0 Datc) �1. (Name of Con(ractor) -- (Insdrancc CoMaav/Policy Nuncrr) Date) (Name of Coan-aelOr) onsuranc: ComPan)'/POLq. Number) (Expimtion Date) (Naane of Contractor) 0-asuranct Comcan-y/PoUcy Number) (E�Piration Date) (na.ar�addi:iocal r'xci if❑ccci.ry to¢x!u�inforta..�oo pertainins to nL oca'r.�4:-3) ( I am a sole propnetor and have no one worlang for me. ( ) I am a home owner performing all the work myself. NOTE:plc k cw-rc tt:ct.L-jo hcarco�v r�µto employ perioar to&r-.=Lc,.�ccr_—_-coo c-rgna Cori:oo. of on(more th_n thrrx rm t3 in Wjsi the bo noouvcr raid?o«oo the U_C t appurtea:m tbe-co LT ooe Ccnar2Uy occ:dc_cd to be cuiPloyt--unr' the wai c{S tioo Act(GL152-"1(5)�nppliar600 by a homcow=far:U='_x or per==y�Tdmrc Lbc IcPl rtaau of nn enployer uD&r dip\Yorke!'Cocapon�Ad- I unda-'-zd dur a copy of tbii e2atemcar my be f.,,-nrded to tbo Dcpartmcaa of lodw-id Amdcu&OIL—or trn—for tho covazSc vcnf etioa rind ttu U-k c to sl=ue oov'c�Mxkx soctioa 25 A of MOL 152 can lad to the i ,psi -of mmiail P,-- - coas_L r of a fioc of up to S 1_5oo.00 ar.Nc,<�riioarncri of up to one yr r fnd a"il pm th o in tx form of n Stop Work ordo end e rim of 5100.00 i day epuaA me For dq> =-'t u-drily Pcrmtl Nt1IIltK.T --- h4 tp;i --- L01 alum 0 f Licxr>scclPcrnuucc —�� e TION 4.�.,CO"ST12t7CTl;©N SERVICES l Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone =-' k Not Applicable ❑ U1 111 1, Company Name Registration Number Address Expiration Date _Telephone SECTIt}N 10=WaRICE12S'CAMPt:NS TIt I±11INWRANCE:A FID 11T(M.G:L..c.152,§ 5C( )) 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 i New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: =e - 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: 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 oVON 7a•OYMER„APTHORIZATIGN TQ BE,C+OMPLtTED WHEN 1YYI�IE S AGENT OR CONIRAC`�"O A,a'P'Llk ICI R,I3V LDING PERMIT 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 wner 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. Print ffarne Signat a caner mt 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: I cp Northampton Bail ' g Department 15 Main Street oom 100 ��T ' r`, `� 4V>,hYh'a pton, MA 01060 NOPJHM!! t,'k . . . phone 413-5, --1 87240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1,-SITE FNFQRMAT[ON 1.1 Property Address: y �Ip 0, ?z 9 a Q r SECTION 2 JF� OPE,I,TY OWNERSHIPIAU ,HORIZED AGENT 2.1 Owner of Record: C`ial�,e yy 6f;eLe w c zz' Name(Print) Current Mailing Ad ess: a zy- Yr� Telephone Signature 2.2 Authorized Agent: Narnee(Print) Current Mailing Address: �,-- Signatur Telephone T ON g x ESTIMA7E1�CONSTRUCt10�!GOSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee' 2. Electrical (b)Estimated Total Cost of Constructionfror 6 3. Plumbing Suiltfmg Permi#,Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) O Check Number This Section Tor or Official Ilse,Only _8 Date Perri*Num�i�r: Date Issued. Signature E tiilchng Comr6lWone lln pector Qf Btrllclings Data 20 CLOVERDALE ST BP-2001-0171 GIs#: COMMONWEALTH OF MASSACHUSETTS y1ap:Block: 12C-052 CITY OF NORTHAMPTON Lot: -001 Permit: Building Categ_oa:roofing BUILDING PERMIT Permit# BP-2001-0171 Project# JS-2001-0282 Est.Cost: $2900.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TODD BOYNTON 126807 Lot Size(sq. ft.): 11499.84 Owner: YUGIELEWICZ CHARLES Zoning:URA Applicant: TODD BOYNTON AT: 20 CLOVERDALE ST Applicant Address: Phone: Insurance: 83 SILVER ST (413) 772-8829 GREENFIELDMA01301 ISSUED ON.8116100 0:00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING 1 LAYER 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 8/16/00 0:00:00 1544 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo