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DEPARTMENT OF BUILDING INSPECTIONS —
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
WOMCER'S COMPENSATION MSURANCE AFFUMVIT
1ccnscfr 11) e)
principal place of business./residence at:
__(Phone:=) 5� J
(strc ty/stair-In P)
do hereby certify, under the pairLs and penalties of perjury, hat
i
( ) 1 am an employer providing the following \vorlter s colnpensanon coverage for Inv
elnplovices work�ang on this job
CL 07
(La=nc2 Corsr,,) (pclie:? u Il cr) (Expiration Due)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listen below who hive the foiloWU' P worker's conoensadon oohcies:
(Name of Contractor) (Insurance ComPanyrPouc, Num!Yr) (Ex?ifauon Date)
—
(Name of Contractor) -- Ras-d ancc CotnDanv/Polio Numccr) (I x'oLm6on Date)
(Name of Conrractor) Gasurance CompanyfPolicy Namb r) (Expiration Date)
(Name of Contra(nor) (Ii15U=C—_ Company/Poky Number) (Expiration Date)
(auach additional ixC(if ncocur:to incttldr infortni.�oa pertnin:ng W ell 0000-�)
( ) I am a sole proprietor and have no one working for me.
( } I am a home owner performing all the work myself.
NOTE:plcsc be aware thn wUo homoovmcn wbo cmplay Pc-lo=w do m=;..,caan*r,was:j 1, oo or rcpau Work an i d. _11ing of
ao(more than thma units in wfncb the bomoor w rradcr oc oc the Bounds zppad a..n6 thccto oo(generally wanda-cd to be
employa3 undo the wm+&i oompcssdion Act(GL152,s 1(5)�appticaboo try a bomcoavcr for e dame oc permit may evidco-tl:e
Ic-pl ctxttu of an employe<under dw Wockzet CboA>oosa Act
I undcruaad chit a oopy of thu eat® may be fo�nrdnd to the Dopartmcnt of lndtu'sinl AaadearJ Offioo of In;v—>oo for the
look eovaxgc vcnfrcrtioc clad that f_iltac to tocurc covn-,' a under socxioa 25A of 1.(OL 152 can Icad to the imposition of aimintl pcaalUcs
oomiumg of a fine of trp to S 1,500.00 androc imllriso�of tap to ooc ycar end civil pm ilia in dx form of a Stop Work Ordcr amd a
fim of S 100.00 a dly agniml me
Foe dcLucme�r.l t1�e ooly
� Pc/remit Number
. 1"41 Pn Lot�1 -
ignatu of Li hairier
SECTION 8-CONSTRUCTION SERVICES
L Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Corniany Nanib Q Registration Number
Q G - o — 3
—
� /U� e
Address r� Expiration Date
CC" �Gvyy\, W elephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(S))
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.
I-Signed 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.
V Homeowner Signature ZI 2iz
( . D I, F; 0 e Iicabie
F use_T1177
placement Windows Alterations) ❑ Roofing ❑
Doors ❑ry Bldg. w Signs [ ] Decks [ ] Siding[ ] Other[ J
Brief Description of Proposed Work: o� f'� o,v
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
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-7,c�✓�-+ as Owner of the subject property
hereby authorize to act on
my behalf, in all matters rela ve to work aut orized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare t at the statem nts 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 ys
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
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:
Gity�fNorthampton
Fphone difti rtment
a!in treet
Room 100
Y —rfbrMW-n ton' ra A 01060
p 413-587-1?40 x 413.587-1272
APPLICATION TO CONSTRUCT-, , REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This S Yc:n tp b com feted offiG�r
7—wnt�--� ► 'I o-�—�— cne erays'stri+#
Elm St, Dkirict :blstrict"
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT :
2.1 Owner of Record:
F-v-QY,c-r s W, OcL yA w e_ l f
ame(Print) Current Mailing Addr ss:
.{� P
Signature
Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address: —�—
Signature Telephone — 0 '3
SECTION 3 ESTIMATED CONSTRUCTION COSTS A
Item Estimated Cost(Dollars)to be Official Use only
completed by ermit applicant
1. Building 000 (a) Building Permit Fee
141- f
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Cheek Number Q
t Thin Section For Official Use Only
Building Permit Number: -d-& 1 Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2002-0964
APPLICANT/CONTACT PERSON Larry Paquette
ADDRESS/PHONE 40 East Green Street (413)527-6375
PROPERTY LOCATION 26 CAROLYN ST
MAP 17A PARCEL 077 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
TVeof Construction: INSTALL REPLACEMENT DOORS&WINDOWS ON ENCLOSED PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 100679
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF0RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Stre ommission
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2002-0964
GIS#: COMMONWEALTH OF MASSACHUSETTS
�:.t! .077 CITY OF NORTHAMPTON
Lot: -001
Permit: B u i i d i ng
Category: BUILDING PERMIT
Permit# BP-2002-0964
Project# JS-2002-1563
Est. Cost: $8000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sg.ft.): 9888.12 Owner: CARDWELL FRANCIS W&BEATRICEH
Zoning.URA Applicant: Larry Paquette
AT. 26 CAROLYN ST
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375 Workers
Compensation
EASTHAMPTON MAO 1027 ISSUED ON:5113102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOORS & WINDOWS
ON ENCLOSED PORCH
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:
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 5/13/02 0:00:00 3028 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo