17A-293 �.�itAlfp2.O
0 C�ztt� of 'Narillamptolt
4{ B �a54 HC1j f;b[tt4 -�
DEPARTMENT OF BUILDITjG INSPEaNONS
212 Main Street Municipal 13uiicling
North all pton, 1f ass. 01060
WOM,�D,R'S CUMPENSATION INSURANCE t1F1+IDAVIT
(IicenserJpermiucc) ���
with a principal place of busuiesslresidence at
(phone'{l
(Stmre:Ucit}/st:1tclzip)
do hereby certify, tender the paims and penalties of PCTIry, that.
( ) I am an employer providing the Followim_� %voi-kci's compens lion coverage for my
employees working on this job.
(Insurance: ampany) (Polio;Number) (I xpiratien Date)
I am a sole proprietor, general contractor o omeowner (c c1e oriel and have hired
the contractors listed below who have the following wor, s compensation pe!icies:
(Name of Cont c r) (Insumnc: Coinnany/Polic-�Numh---r) (Expiration Date)
(Name of Contractor) (hsuranc-_ Comnany/Poki ,Number) (Expiry-nn Date)
(Name of Contractor) (Insurance Date)
(Name of Contractor) (Insurance: Com>11jy/Poli(_ Numb r) (Expi :;on Date)
(att.ch: !iticctzl s!,t if ncccvry•o rill ccc:.ram x�)
O I run a sole proprietor acid have no one for me.
O 1 am a home o�'mer pelYOnnin� all the Nvork myself.
No,n::plc�ac be aware tiat who=-play to d� a rdcauicc ca r����',a cr-CPU if wo;it cn a d".C11ing of
not mtoc<t}Ln tear"uni�s in t•.{:ie't;Ix k�,:xvwZ;cr rriid.-s cr at tL,.-�u;r!t zyr�tttc:.�n2 LSc,^cfo e:c txt�v-really car::c:-cd to be
employes unties the woika's x sstim Act(GL152,�1 1(5)),a[ 1:a en by a hot=oO NT-i fcr n c�Permit r_ c,i&r,r, 01C
It gal ctatuz of an o�ployor undsr d_0 woctccic Cotiuxmztion Att
I un,1=tXad thzi a copy of tllu cute ul nuy bo forw dod to ten Dq tmcal of l,,d L t i J Milartf OfIioo of[rakwco for tl o
covcagc vca£catioa and Heat Eilurc to recut covcrago and r section 25A of MG1,152 can Icsd to dx imposifion of C"110-11
prnsltia
coaiisting of a fine of up to S1,500.00 of up to cne)Tr n.)d civil peraltics in dY fcxin of n Stop W c Orc er and a
firm of S 100.00 a&y tg,-�imA ar_
For mfy
Pczmit Number ---- --
Sip�lturc of Liccn;ceJPc:mittcc ,�
SECTION 8 -;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : — -- --- - - ---- -- - -
—
License Number
Address Expiration Date
&&,nature Telephone
_ R ,ri4
9RegsteretlHorrielrtiprovement``Contractor „�b � -, ,_,.�.�`, Not Applicable
❑
Conipan�Narne Registration Number
Address Expiration Date
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 affld�—It
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
., �Honie®swner Exemption
11.
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 buildiny, 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 fo:-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 persons
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 5-'DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ J 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 ❑
sa`If New house aritl or.'atltlition`to existing tiouMnF!, complete:thellfollowin :
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?
In. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes_-___No
I. 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
as O.vner of the subject property
hereby authorize to ac; on
-------- ---------------
my behalf, in all matters relative to work authorized by this ouilding permit application.
Signature of Owner _ Date
r
as Ov ner/,Author zed Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature Owner/ gent 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
*ize
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 `FES, describe size, type and location:_
City of Northampton Status of Aeg 1.
Building Department Curb Cut/�
212 Main Street Sewer/Sep
Room 100 Vlater/Wela� t fa
Northampton, MA 01060 Two Setss of Str e
phone 413-587-1246 Fax 413 587 1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR.. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 1
This section to,be completed by office
1.1 Propel Address
Map Lot Unit
Zone OVerlay District
J� Elm St. District_ CB District __—..--
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner o Record:
nr ,
�doress
Signaurt _—_- _
2_2 Authorized Agent
I
`Jan r 0 rint; Arldress:
I
Signat�,re eleph,-)n�
SECTION 3 _ESTIMATED CONSTRUCTION COSTS
item Estimated Cost ("Dollars; : I Official Use Only
completed by p a, r
o ,
i �uildinp /yam �// A (a) Fuiidir�g Permit Fee
,irnated Total Cost of
Cr rst�-uction from 6L-
3. Building Permit Fee
i
< <+ 1 chanical (HVAC) �–
5. Fire Protection
6. 1 otal = I + 2 + 3 +- 4 + 5 — Check ;Umber
This Section For Official Use Only
Building Permit Number..� _____________._--___
Date Issued:_--_- ------
Signature: ---
Building Commissioner/Inspector of Buildings Date
100 HILLCREST DR BP-2003-0626
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-293 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
CateizoU: woodstove BUILDING PERMIT
Permit# BP-2003.0626
Project# JS-2003-1032
Est.Cost:$1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg.ft.): 20298.96 Owner. WEINTRAUB DORIS
Zoning.URA Applicant: WEINTRAUB DORIS
AT. 100 HILLCREST DR
Applicant Address: Phone: Insurance:
100 HILLCREST DR (413) 586-7980 O
FLORENCEMA01062 ISSUED ON:1113103 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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: K 2— - Q 3-
: AL
LY!
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON Vf0—LATW90F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/13/03 0:00:00 138 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo