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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Muss. 01060 '
WORKER'S COMPENSATION INSURANCE AF MAVU
(li ce>LZerJpc-rmi ttee)
with a principal place of businessJresidence ax:
(phonell) 2,
(st.reet/d ty/statdzi p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnstlran� C ompauy/Policy Number) (Expirabon Daze)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aiiach additi al sheet ifnece=ur:to iadude infornnricia pertaining to all co¢'radors)
I am a sole proprietor and have no one w✓ork�ng for me.
( ) I am a home owner performing all the work myself.
NOTE:plcaac be aware thai N U,* c hoafcaAncra who employ pasora to do mainicc i =3s ua.ioa or repair wo;k on a dwelling of
not nzoce than thtca trnitt in tcaic+t the hon»owacr r,=dcs or oo the g:ou.�appurtenant thacto arc o<X gmcmuy coalidcrcd to be
employers and,cr the worker's acarpai oct Act(GL152„sa 1(5)�application by a homco Ana for a bccax or permit may cvidcaoo the
legel statue of an employer under tiro Wocko's Compmzalion Act
I understand that a copy of this rtairmmi may bo forwarded to tho Dc{nrtmcnf of Indtt d A,6dt..&of5 of[=AW rice for the
oovtmt VcrMCalion anal that failure to acatrc coverage under scxiioa 25A of MGL 152 can lead to the imposition of criminal pcnaltics
ooctistiag of a fine of up to S 1,500.00 and/or uaptisonuxat of up to one year and civil penalties in the focm of a Stop Work order and a
fins of S 100.00 Icily tgniaA tom.
f9 Foe&P-ttnt-w use poly
% r Permit Number
Mag{{ Lot#
Signature of Licc nittee
SECTJON 8 aCONSTRUCTION"SERVICES
8.1 Licensed Construction/Supervisor: �r Not Applicable ❑
Name of License Holder: 1/� !y"S �i�r' A 6 3,�)6,
_ License Number
J
Address Expiration Date
Signature Telephone
iM 0 / p f Not Applicable ❑
OE ry M/ y /
Company Name 11 Registration Number
/ 7 - ')12- lby-
Address Expiration Date
,r.
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 affida
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(.
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' D SGRI PTIOU" PROPOSED YVOR chuck all a licable 3
F l RL'S 3Y 3 3i Yr d _ A 'n aN M'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 7-11w t ' [
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
6a, IfNeur�ho e�a"�d�are�a�lditiorito ez-ist�ng�housing;�:cornpletetfi�`e�fbllou ,ir� :
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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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.-AGEIVT>10,111 CO NTRACTOR'APPLIES FOR BUILDING PERMIT
as Owner of the subject proper
hereby authorize It,-) -I to ac:
my behaXin all matt s relative to ork authorized by this building permit application.
Signature of Owner(-/ Date _
j(j X� /.% �% ' /jt✓ C as-9wasr/Authorized Agent
hereby decla-re 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
o'
Signature o- wner e / 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
s 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 ur 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:_
r
�
/ ty orthampton
Qi Department E r
I ain Street
AUG 1 5 2001 m 100 a s
Northpmp on, MA 01060 ens
DEPT OF 0 7.1 40 Fax 413.587.1272 Plo�tS�eJPla
NnRTKA►4P10N,MA 01060 Other Sp�efy b
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section two be�wWcompleted bff�ce
1.1 Property Address:
Ww
t
MapLot 11A � t
Zone.,
Overla District
� y M
T Elm St.District CB Distract
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K!ame( r" t) Current Mailing Address:
e6 t .1 Telephone_
Signature -.
2.2 Authorized Agent: rA
Name(Print) Current Mailing Address, /L`
Signature Telephone
SECTION';3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
coD4Vlete d by ermit applicant
1. Building ®� (a) Building Permit Fee
2. Electrical I (b) Estimated Total Cost of
Constr uction from (6) —
3. Plumbing Building Permit fee
I 4 Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
l$1 N�?R�`). MA 'L BP-2002-0177
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0177
Project# JS-2002-0283
Est.Cost: $1494.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sg. ft.): 718 7.40 Owner: SCHECHTER BARRY D&KATHLEEN L
Zoning:URB Applicant: DE Sheppard Roofing
AT. 181 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:8115101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE ROOF
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/15/010:00:00 2280 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo