17A-128 'T
MA G1060
Z DGI
X, vED-T In%, NIENT LE
Tire staz? al-lows 'L"he honn�wmef the I-liziat-=der 7SOC-2ya 108.3.-,4r to ti
a-c; -C r.:.`"� :,-c,-. The szae, d•tfres
who o-v;--z a 'des or ei:ds to be, a are or two
_parc__�, o12 wrj he/she resides filmzil7
III -��s acot-sol- an&cr fa=- , s=cz—,Tes-
d4w azzacLed orde-ached- f to sac�!,, =
Person-w#0 Constructs More than one home In a twc-ye •-Period sLaJT not be cc
ihorn_-
f.-F the C-V Nor-Lh;: Dto -7,=-ts "--y erscra(s)who sedL to
I y of n p -v4 — be -
C tel
eX�=pL.GZ, tO L1.1ei r 0 -i—E C r
that by doLrz so vor. become responsible for complilamce with state buEdinz codes
and re:Tjlafc=_ The i=eacuon prCceSs'reqL-71-reS that the boil-is;depwent be called'
to ms-oe,_-, at cus st tages, wmch include foundation/footings (before bacIdEA
sr,-notube holes rbefore vour), a raL,,sh buRdins-insvection(before work-is
cc,r_ce:g�. reaulz-ed)aad-A f-Ing, h ding ims eg-tigm. The
u;M-mg de ese ed- faEure to
quires th , i=e_-tioms before the-work
Secure these insvections can result fn failure to obtain a certificate of occuna.ncv
LF the hcm ec-wan-_-hires.ozhiar trades -L 0 p e::o 7-ork(e,ec=call, plumb in g Has) tLe
11 o e 0 Ti w U.'r be resuC.nsble to r-�I-sz-,re that the trz-65s lire se---,,.ire their proper-
per:.
--ts L127 cozjuzct on to the buLldi=per=:issu-ed and that they get their required
L-1-spectio ns-Farure of the L—d vi dual Modes to szeczye He pel='ZS and insP e--t'�Tons as
e:� cz D Y',L t] such time as toe proper p er=--its and mspec-t.,ons are
T7 de
tie above-
p.m. owne.-lreszident's signnture re-questing ele ptioi
ca-!I to S,:Led,-,j_ail r-C-LIi e--i bLT;l "-z j -pecr,,jons necessary for the builds?p e"=I,
Issued to me_
A
r _ Office of Investiga!ions
_ 600 Ti as?i ing ton Street
~^ Boston, .MA 02111
www.mass.g ov/dia
V,Vorkers' Compensation Insurance Affidavit: Builders/C onto-actors/ElectriciansTILmbers
A r-ollc2int information Please Print Leaibiti
Name (Business/Organization/Individual): _
:7LL.11 eJJ.
City State1Zip: jC i, Phone : __ 5.4,
.`.re ,ou an employer? Check the appropriate box: Type of project(required):
1 i I am a employer with =� ❑ I am a general contractor and I 6. ❑ New cons—niction
employees (fa and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ R--nodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers'
9. F7 Building addition
[lv'o workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.F-1 lectrical repairs or additions
I am a homeowner doing all work officers have exercised their 1 l.❑ Iumbing repairs or additions
myself. ['-No workers' comp. right of exemption per 1VIGL 12. Road repairs
insurance required.] _ c. 152, F1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
`Any applicant[hat checks box#1 must also fll out the section below showing their woricers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors tl at check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy=or Self-ins. Lie. N: 00 b G � S-0 .Expiration Date:
City/S S i
: Job Site address: � ` _ tate;Zip: 0 1 � G
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for ' rage verfication.i
I do hereby-cerri , unrtz;the pazns cr3rr erraitre e�pe,fax; iat the information provided above is true and correct
1�S i mature 7 _� —,�/ � Date-: ...
3 '-7 ----
Phone=: ---
_= f town o fficiaL
fCity or Town: Permit/License r
I Issuing Authority (circle one`:
_- Board o?Health _. BuEdiin_Dec"artmeat 3. Cir,lTown Cler:i -'..Electrical Ins pe:for 5. Pla m.0:n_ Inspector !I
6. Other
II Phone
Jr:ti t P .'Si)P:'
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
� Q
Name of License Holder: \ (] / 9 _
Licen(-)Nu
� mber
� �
Address i Expiration Date
(0
Sig re Telephone
9.Registered Home In rovernentContractor „ „ , NdtApplicable ❑
Co r)anv N Registration Nummber�
Ad ress Ex Nation ation Da e
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 affidavit will result
in the denial of the issuance of the bui4ng permit.
Signed Affidavit Attached Yes....... No...... ❑
11a- Home:Diner Ekempt on
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 1083.5.1.
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-vear 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks Siding[0] Other[Oj
Brief Descri Rti p ed
Work: � CJI� --r �� ti'y [��,�pv, OF'QOLJ-
Alteration of existing bedroom Yes No Adding new'new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If New house'and or addition to ezistinA housing.complete the foI[owin± :
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. Masscheck Energy Compliance form attached?
h. 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
v� N as Owner of the subject
grope 0C�
hereby authorize
to act on e alf, in all matt s rel ive to work authorjzed by this building permit application.
Signature of Owner 711 Date
t
as Owner/Authorized
Agent reby dTcare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Sign under th ains and enalti s of perju
- --- -�
Print
Signature f Owner/Agent Date
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front m
Side L:,......._._. R. _..,._ L.'_._.
Rear _ ._
Building Height _ --•--
Bldg. Square Footage _..... %
Open Space Footage _„ _ % - -
(Lot area minus bldg&paved
parkin )
#of Parking Spaces
Fill:
(volume&Location) —•
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES __._._
IF YES: enter Book ,_ Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES,then a Northamptbh Storm Water Management-Peirnitfrom the DPW is required.
s'
. Department use only
City of Northampton Status of Permit:.
Building Department Curb'Cut(Driveway Perm it
r r_f 212 Main Street Sewer/Septic Availability
:Room 100 Water/Well ffvailabili�- -
Northampton, MA 01060 Two Sets of StrudturaE Plans
phone 413,x87-1240 Fax 413-587-1272 PlotJStte Plans
Qtliei Speafyf
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
1.1 Property Address: This section to be completed by office
l7rf-�c
Map Lot Unit
1 Zone Overlay District
Elm St District C6 District
SECTION 2-PROPERTY OWNERSHIPJAUTHO iZED AGENT
2.1 Owner of ecord:
�7 L CK a V
t r i
Name(Print Current Mailing Address:
Telephone
SigSu r e
2.2 Authorized A ent:
V)
Nam rint) Current Mailing Address
U � �
Signatur Telephone-T
SECTION 3-ESTIMATED CONSTRUCTION COSTS°
Item Estimated Cast(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=(1 +2+3+4+5) Check Number
This Sec ion For OfficiatUse.Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner%Inspectoro w rags' Date
;. 3151BRIl 1911%0` BP-2009-0704
GIS#: COMMONWEALTH OF MASSACHUSETTS
a r .10 ::ilk w M e CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2009-0704
Project# JS-2009-001029
Est. Cost: $2000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq. ft.): 11412.72 Owner: LAPINSKI EDWARD J&ANNA MARIE
Zoning:URA(100)/ Applicant: BOB THIBODO ROOFING & SIDING
AT: 315 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 O WC
NORTHAMPTONMA01061 ISSUED ON:211812009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL NEW RUBBER 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• Date Paid: Amount:
Building 2/18/2009 0:00:00 $35.003208
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo