17A-052 (3) ��tvJfJ,
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AI 'M a76 14(11 nLrt 15
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION ENSURA-NCE AF U MVI'I'
(li�ns::Jpermi ace)
\,.rIth a prICIpa] place of business residence at.
- -- �3l✓e� �e�.,/%� (phone
(SITr-'Inc]1 f/S12IGf2]P)
do hereby certif),, under the pains and penalties of penury, '01 21.
( ) I m an employe; providin- the iollov vine "vorker's colnncnsanon coven-e for my
emplovecs Wor-�7111g on Ills Job
(lnsurnc-- Com- T=v) — — (PoLc-,N�itrr) ---- - —(r�pir�on Date)
( ) I am a sole proprietor, general contractor or homeowner (CU-de one) i—,Id have hired
the contractors fisted below who have the folio%-Y* worker`s comens2 on policies:
(Name of Co.^.c.accor! -- (lnsuranc:, L01110311)-i"ohc-, NLLm—,) (}:?:y)lri)UOn Dmc)
(Name of Contractor) (Insuranc: CompaayPo!icy Numcsr) (ExPI- rion Date)
(Name of Connacror) (Inatfance Company/Policy Numbu) (Expimuon Dale)
(Name of Contractor) GMUfaIlc-c Company/Policy Number) (Expiration Date)
(aaach addi'Goml s1c ifnoc-sz to induct~iafaaii,00 pczta' w.11 oo�a.c_o:�)
KI am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:plcsc be aw-i-m that wbilo boa=wncn wbo employ Pam w do m,iri.., act coast,tioo c r repair work oo a d.-Jl_g of
not mom tban tbroc unit,in winch the bomoow rtm&=or oa the gounhr xppurteasai threw ar no(Crno= y coandaed to be
etrtploycrs tinder the vlockcr',oempcas4oa Act(GL152,=1(5)} applieaboo by a homoow=for a Gcma c a pa-mil may evidence the
1cga1,tams Of&n oaiployor under dho Wocicde Coaspomatioa Ad
' t undvsiaad that a oopy of tbu c tc may bo forward.ed to tbo Dcpwumc of lndutrial A=dca&OQroo of lrnaui000 for the
oov=sc vcriGcstioa and that L-ilurc to toa=oovcrngc under socUon 25A of M01,152 can[cad to tbo imposition of criminll Pc'3AWi
ooasisiing of a fine of vp to S1,500.00 and/or impriaoamea!of up to ooc year end civil pevshirs io the form of a Stop Wort(Ordrr and a
fire of 5100.00 a day against me
For poly
Permit NttmbCr
maps _ Lot n __
signer of LioctLSCC/Pctmiticc
£CTION$ -COMSTRUCTION SERVICES
A Licensed Construction Supervisor: Not Applicable J;1'
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
i
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Pe ,�°t_a &00-/ Telephone c�j y7s"—oZ77S�
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 affidavit
will result in the denial of the issuance of the building permit.
gned Affidavit Attached Yes....... ❑ No......
.: gQ
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
Aoft-
�MCCTION 5 DESCRIPTION 0 PROPOSES WORK checl�all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] 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❑
6a If " fliti
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
I , 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
I,
as Own uthorized A
hereby declare that the statements and information on the foregoing application are true and accurate, to the es o my
knowledge and belief.
'gned under the pains and penalties of perjury.
Print Name /00�
Signature of 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
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 y/ 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 v
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:
• N
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 INFORMATION
This #ion tac cam Qf + r
1.1 Property Address: 3
r nn
O�
�
F
o%��Q 1060 ntrict
l 'n i
El, Stc nib ,+ lstrl3
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT"
2.1 Owner off qRecorrd�:�
ame(Print) Current Marlin Address:
s - 9y6/
Telephone
Signature
2.2 Authorized Agent:
Name(Print) ✓/� Current Mailing Address:
Signatur Telephone
SECTION'3 - ESTIMATED CONSTRUCTION COSTS
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
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(I + 2 + 3 +4 + 5) 00 Check Number
This Section For Official Use Only'
Building Permit Number: p�� Date Issued:
Signature:
Building Comm iss loner/Inspector of Buildings Date
4 ,
156 OAK ST BP-2000-0925
GIS#: COMMONWEALTH OF MASSACHUSETTS
✓jp:Block: 17A-052 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-0925
Project# JS-2000-1698
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: TODD BOYNTON 126807
Lot Size(s�]c.ft.): 6229.08 Owner: WOLOSENKO SANDRA L
Zoning.URB Applicant: TODD BOYNTON
AT. 156 OAK ST
Applicant Address: Phone: Insurance:
83 SILVER ST (413) 772-8829
GREENFIELDMA01301 ISSUED ON.4125100 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 4/25/00 0:00:00 517 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo