17A-056 (2) I
(Mill of Nlarfljaliip�ml
- 6 �[5OR(Ii Its rtIs
DEPARTMENT OF BUILDING INSPLCI'IONS
212 D1al Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFF DAVIT
with a prVicipal place of bushmsdresidence at
f
-- - ------------
do Hereby certliy, moor tI c pains ;id ynalkes Oi t)P.Ipuy thm
I an an employer providing the following, .�.,oike&s comnensnimil coverage or Iny
employees working on tllis job:
onam ma: Compaq) (_Police;Numb--r) (Lxpir--tlon Date)
O I ant a sole proprietor, general contracro; ur homeowner (circle one) Pad have hired
the contractors listed below who have the workers compensatiorn policies:
(Name of Contractor) Dal)
(Name of COP.traCior) UPAUMDA ( O:;I:;1:iY1� 0 1Ci NIIII]trr) (t:XiilrailCn D2IC)
(Name of Contractor) jwurallcc C0nr:2nyiP0liq; Numbxr) (I=x;:.ratio Date)
---- ---------- -
(Name of Contactor) (InsurjIC Coral;:_�Iy[!'oEcy Numi>^cr) (F::pi mmn Date)
i
I mll it solo lirop!ietol i'.IIQ have no or t0! II?e.
�• ) aln a home ovine: perforl111I1� <Ll
No"n":plc-ac be aware that ws ilc tx<nco t1r a :�c p!cry 1r::r to<gr_.v casncS a:.rt cc m cr air,<<,Iyc<n._ i cl!i c!`
not InCYe thin dice waits ocr:`..U _..:i zpputtcr•�t Lccto r c txt�e rsall}'c r.:: rcC:c h
ca ployc� xics t}�c twr cts ar��sstirn (GL152 31(S)).zrFli�aticn by a homcot��rr fora heave cc
legal rtatua of an omployor under tLo Wcxkcr'i C x s{xrnal on A_CI_
I undo.-Y wd this a cony of O},-ctatcn:cnt nuy bo for-d-1 to tt;o of l;---o for ttn
covet-age vaifiealioo and that fail=to!stye mvtt-n90 tu:3:r 25A of MaL 152 can Iced to tho i'll—ifian Of rinir l mtalt:u
cbmi ig of a ftne of up to.S 1.500.00 att'Jcx i.^.:+riu a tic: of tip to cn year n:�d civil txnnl6cl in dx f<�rnl of a strt W cry On: !Lrd a
f to of S I00.W a dsy igtinM ar_
6*4 Lot
For dq;utrtxi Cil trio qtly
f� - pc?mit Ntunbcr
Slgnaturc of-I.tcc-:; cJfcrm;ttr, ?I-' I
3 i _
SECTION 8 k 00STRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑fin
Name of License Holder : –7-0 0 wl W V C,CT `c, �l C S (3 -5 `2
s ' b
Ae / License Number
JJ
Address Expiration Date
T Cj �1 S97� �
Signature Telephone
Not Applicable ❑
Registered come, mprovementContractor:
Company Name Registration Number
1 � � l ISio1 e ✓��► G i -g:�/C)
Address Expiration Date
5 L�7 L�
Telephone
SE E'
CTION 10 !WORKERS';COrAPENSATION 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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
i
o= ® x ner TO em 'ti :n'
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 fur 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 ►nay 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.
I
i
Homeowner Signature
i
i
.d yr'
SECTION 5 DESCRIPTIONIOF0'PROPOSED WORK(checkfall3apalicable)
w , p
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: r S �Q -e `1 5 C M'
15
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet D
66a`ffl New house and or ddition to eXi's'ting"=housing,:complete the followin :
a. Us of building : One Family Two Family Other
b. Number c, TaQms 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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is cor�truction 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 .
11.`Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENTOWCONTRACTOR APPLIES FOR BUILDING-PERMIT
Pot U C �a r p�q S as Owner of the subject property
hereby authorize
7^0^1 to act on
my beh in all t;t e r I i o work au horized by this building permit ap lication.
Signature of Owner Oate
(9VI .7 `C{ /1 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.
Signed under the pains and penalties of perjury.
—1 ors
Print Name
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 X
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:
City of Northampton Sfatu Hof Per< tt•
Building Department Crrb Cud/�r
212 Main Street SewerlS
Room 100 rll v
Northampton, MA 01060 T' oSets�of tr c a, s '
hone 413-587-1240 Fax 413-587-1272 P'o %Site Ptans � �.
*
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address-
1d3
This section to be completed by office
4 Cl"'e S Ft Map Lot Unit
A0,*1 10/1 z �A OIL) Zone Overlay',District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: :
-JVA'/ A
Name t) Current Mailm� r ��� / /�
Teiephone
Signature
2.2 Authorized Agent:
-ro 401C
Name( ``pS) Current Mailing Address:
Signature Telephone
SECTION-3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed b ermit applicant
1. Building (a) Building Permit Fee
2. Elec"rical (b) •: timated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) ��f 7. D O Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1.231AKE ST. BP-2004-0344
G1S#: COMMONWEALTH OF MASSACHUSETTS
AvfA:31ock: 1A
-056 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0344
Project# IS-2004-0500
Est.Cost: $5594.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Quinlan Builders 053107
Lot size(sa. ft.): 22564.08 Owner: MARDAS PAULA
Zoning`URB Applicant: Quinlan Builders
AT. 123 LAKE ST
Applicant Address: Phone: Insurance:
5 Hillside Dr (413) 585-0949
HADLEYMA01035 ISSUED ON.9129103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP SLATE & SHINGLE ROOF
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:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/29/03 0:00:00 3681 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo