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17A-169 (2) 4�ttAMP�O O a ae �xsssrhasrtta a m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORICER'S COMPENSATION INSURANCE t AVTT I, (li censee/permi tzee) with a principal place of business/residence at: (phonet#} (street/city/staie/ap) do hereby certify, under the pains and penalties of perjury, that ( ) I am an employer providing the following workers compensation coverage for my employees working on this job: (Lasu.rranee Company) (Policy Number) (Expiration Date) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) ,f (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Innlraace Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (E)cpiration Date) (aUadl additi onal s+xct ifnccc=vry to include infurmi.'ioa pertaining to all o«itrncion) 4 I am a sole proprietor and have no one working for me. O I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ pczom to do ma ntnaa cc !Szr=on or repair work on a dwelling of not mode than thmo unit,is which the hoa»owncr raid,=or on th,c g<ourxis appurtenarrt thado arc ry-t Ecocrally coaridacd to be employers under the warmer's a=mpensatica Act(GL152,--zs 1(5)�application by a homcouvcr for a Lccose a permit may cvidcnoe the legal etatue of an employor under tho Workcer,Compamatiou ACL I uadcrrtaad thrt a copy of thin rrat=zcd may be forwarded to tho Dcp<vtmcaf of Indzrsfriai Accideats'Offroo of lz�for tho coverage vcril'cation and that failure to&earn covttago under sectioa 25A of MGL 152 can lead to the imposition of criminal pen&W(es oomisting of a rule of up to S 1,500.00 and/or impris�of up to one year and civil pcmltia in dc form of a Stop W on Onda and a find of 5100.00 a day ippinsl mr- For&p—ft—al—only • � ``O� Permit Number t Map# Lot# . Signature of Licenser/permittee e ( v SECT�bN 8 CONSTRUCTI0 ;SERVICES 8.1 Licensed Construction ervisor: Not Applicable (❑ Name of License Holder License Number KK (Cr- a4- 0 3 Address Expiration Date Q -to-J�- y�3 Sg 03 a� Signature Telephone Not Applicable ❑ Company N I Registra ion Number is? Qk1b#N a so Address Expiration Date Telephone4il L S o3aO 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 _ X3,3.3. SECTION; DESCRIPTIONOF3PROPOSEDINOR ffieckall a livable �•.fi9�,x �3r.«�� i�x,v`%aR.;.hS A>>r.P£,rT3�Y x ,hll3r>» „4 133p\ . �aai.�.�, aF New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedro m Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet o s f Neriv house Iii o° chit°on.,to ez�stin° housin com I"ete�Yie fol1,o, " 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.AGENT OWCONTRACT,OR APPLIkS F6kz,BUILDING.PERMIT • 1. ' It &Wks Owner of the subject proper hereby authorize �� �� Qd to act my behalf, in all matters relati�v�o work authorized by this building permit application. Signature of Owner Date 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. Signedl�r-the amend nalties 6 Pr i Name "1- ,- O � 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: ONNNOWNEMW t City of Northampton Building Department 212 Main Street Room 100 to;14 Northampton, MA 01060et a a phone 413.587.1240 Fax 413-587-1272 Plot%Site . 3 Ot e�i at, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section t k,completed by*off>lCe 1.1 Pro ert Address: + t" - Map L t � AIN9' ZoneOverlaysbistrlct Elm St. District CB District SECTION 2- PROPERTY OWNERS HIP/AUTHORIZEDiAGENT 2.1 Owner of Record: Sa s 0 Ao ItS Name(Print) A vim% C. Q �'Y' Current Mailing Address: z A ' �. J Telephone Signature — 2.2 A thQori ed A enI oNe Nam�t) Current Mailing Address: 401 Wei 'KI C770� o3 "I" 1 Signature Telephone SECTION'3 - ESTIMATED CONSTRUCTION COSTS y 64 S 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 = (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 BP-2003-0037 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0037 Project# JS-2003.0102 Est.Cost: $4285.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT D THIBODO 118441 Lot Size(sa.ft.): 8537.76 Owner: DRESLINSKI STAN& Zoning:URB Applicant: ROBERT D THIBODO AT. 16 HOWES ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-8966 NORTHAMPTON MAO 1061 ISSUED ON:7110102 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/10/02 0:00:00 1161 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo