17A-262 (4) " q
i
4�L PLO
B , e (rx:E� lord ��#I��IIt�J�IItt
9 Bl+taaaciltssctta'
g
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORI{ER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
(phone#)
(6treeUcity/sWd2ip)
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 woriang on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 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)
r.
(Name of Contractor) (Insurance Coinpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(attach addition1 shot(ifnoocnixy to inchide information pertaining to all ooh rs)
i
Vy' am a sole proprietor and have no one wolfing for me.
( ) I am a home owner performing all the work myself.
NOTE:plea'be aware that w6ilo h0mc0%N cM who employ persons u do mamimxaeS mud oa cr rc,au work on a dwmlling of
not more thaa thrco units in Whidt the homeotzvcr resides or oa tb t grounds appurtcnaai t}x c(o arc ool gcocsLU coca dacd to be
employer,under the woe s-ap=s4ou Act(GL152,"1(5))�,application by a homcowmr for a lactase or permit may evident the
legit ctahu of an employer under the Workeez C.onV-co ion AcL
I understand that a oopy of this may bo forwarded to tho DV"t mt of IndzraLial Aocidmi>OfSoo of Iasrrrsnoe for thn
covaaga vrrificatioa and that faU=tot==oovaago under soctioa 25A of MGL 152 can lead to the imposition of criminal penalties
ooaustmg of a fine'of up to S 1,500.00 in&-mm�srt of up to one year and dvil pc=N cs in the form of a Stop W mk Ord- and a
fum of S 100.00 a day against m
For dcpartnx W use only
permit Number
Wp# Lot#
-{Y of License&permitxee e F
EC 0Q�IV�5��RVIC
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
License Number
0. 1� `;:�/ - G5
Addr s Expiration Date
Sig ture Telephone
r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS';COMRENSATION INSURANCE;AFFIDAVIT(M',GL. 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...... ❑
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 044�2�
S GT�ON F1 0 0 5 Da ic'b e
OWN 0,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ TRoofing
Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Adding new bedroo Yes No
Attached Narrative❑ Renovating unfinished basemen': Yes No
Plans Attached Roll❑• Sheet❑
fN:e o it: . in o s n ffftori e. I,t...
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 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
fTION
SECTION?a-OWNERUTORIZ/ 'TO
,B�COMPLETED WHEN
OWNERS AGENT 0 =CONTRACTOR ApPI I[Es'?LR BUMLf)ING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters rela ve to work au horized by this building permit application.
Sign re of Owner Date
I � , as Owner/Authorized Agent
hereby de re that the statements and information on the foregoing application are true and accurate, to the best of my
knowledg nd belief.
Signed under the gains and enaIti s of erjury
Print Name
Date
Signat a of Owner/Agent
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 F-:ont
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 Issue d:
C. Do any signs exist on the property? YES NO Cl%
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:
f
of Northampton
ing Department
Main Street
t� Room 100
MA 01060
phone 41,3 587 1240 Fax 413.587.1272
-- - _ __ T NS
! AP�+OFZ*14j , , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.SECTION 1 SITE-I:NFORIVIATION
§.
1.1 Property Address:
El sX
ii'it
SECTION 2- PROPERTY.OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: r
Name(Print) Current Mailing Address:
Signa re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building y (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,Bommissioner>Inspector of Buildings Date,
BP-2003-0085
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0085
Project# JS-2003-0175
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(ss .ft.): 11543.40 Owner: EMMONS CHARLES F&EMMONS
Zoning:URB Applicant: James Roberts
AT. 77 OAK ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTON MAO 1027 ISSUED ON:7124102 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI P & 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 7/24/02 0:00:00 1966 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo