17C-241 4�t rT
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
R'S COMPS SATION INSURANCE AFFIDAVIT
(IicenstrJpezmittee)
with a principal place of business/residence at:
�f P CI
(pl;onefr)
(street city/5-tafrlap)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the foiloNving worker's compensation coverage for my
employees worming on this job:
A ; (Insurance Company) (Policy Number) (Expiration Dale)
�,..
I am a:;ore 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)
j (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compa.nyRoGcy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach ukWoml sheet ifneccssary to kwlude infbrmatioa pertaining to all 000fne )
am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whilo homeownerz who employ pc=m to do m i„�con!;ft t oa or rCpas work on s dwelling of
not molts than tbroe units icl which the homeowner resides or oo the grounds sFpurtcnaat ibcccto=clot gc=4y eoosiderod to be
employ=undet the vvorket's compeasstica Act(GL152,ss 1(5)),application by a homeowner for a license oc permit may ev+idcooe tho
lepI status of an employee under the Worker's Compemation Ad.
I undest and thst a copy ofthis mLem w may be fotwatded to the Dopwtmcut of Indsu el Ao64=&OfSoe of Inxuaaoe for the
oovalge ve ficatioa and that failure to soaaro covemp under section 25A of MOL 152 can lead to tba impos Oa of Mmivai penalties
ooaustmg of a fine of up to S 1,500.00 acldloc impr6onmcnt of up to one ytar and civil penalties is the form of it Stop Wodc order and a
fins of S100.00 a day against tae.
For dcpx tms nee od'
PCTTnit Number
Map# I,ot#
Si of Li ttee Date
- i
P � �AA
SECT#ON 8, CNStRIJ�CT�O, ERVCS�
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Companv Name Regis ration Number
Address Expiration Date
Telephone-, '3 3Gf�
SECTION 10-,YYORKERS'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.
Signed Affidavit Attached Yes....... I No...... ❑
- E
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,Sta and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature 7 ��c �✓{Z
"
aR. r�YS _SI 15s
ECT N 5 D;ESCRIPT�ON3F PROPOSED WORKceck al applicable) ;
:.�. Nro.a * .s} .•-
NK
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Wnylt ncza II, �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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
SECT}ION 7a OWNER AUTit�RIZAfiION ,TOBE COMI'LETED WHEN.
O11VNI=l2S AGENT CONTI7ACTOR3AFPL1 5 I OR BUILDING pI=RIV[I7.
c
L– as Owner of the subject property
�
hereby authorize u "L""'�.— to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Rut L as Owner uthois�fm ent
hereby declare that the statements and information on the foregoing application are true and accurate, to the t o y
k nowledge and belief.
Signed under the pains and penalties of perjury.
Print NanTe—�
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 e r 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:
City of Northampton
Building Department
2,12 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
m tel
1.1 Property Address: �� T �s se°tide"ode °` om le ytsf# e3
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A/.
• l y l Gi r �ZMap� t � �
r ��tiC f 7Zo'ne .� r � uerla�s r� P.�
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SECTION 2='IPROPEf2TY OWN,ERSI IP/AUTHQRIZED AGENT
2.1 Owner of Record: .
N QS
N me(Print) urrent M 'ling Address;
�-s Tr N L• ��a2.s 5�/
Telephone _( 5�
Si nature
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s � SSG_
2.2 A hor'zed A ent: '
i
91 G1 IJA
Name(Prin Current Mailing Address:
L1 13-A "-339f
Signature Telephone
,SECTION 3 °E5TIMATI=D t;ONSTRUCT�ION COS'T'S 3r ' � i
Item Estimated Cost(Dollars)to be Offtct� Use'On Y
completed by ermit applicant
1. Building ���� ;(a)Butting Perrtt`:ee
2. Electrical (b) sttmaed Totalostof � ,4
�onstrmcv(
3. Plumbing
I 1Z
'19 Idtng Perms , e f
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2+ 3 +4+ 5) Cleckt`umber a
OW
�i tVn .r Olf�C.1�� : nl �RAi F1
} i wz � � � ��.��� u.. I�; �i'� 3 a."Jv�s��Y �mN,r�j"�aa•�; �' c ii�a,' �u. �"�aj° -a -,�` � a � ° e� �
`gnaure 4M3 f4 �b
6ut12ingolmsstog I � e t pi Buildt,,,g '
105 NORTH MAIN ST BP-2001-0508
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-241 CITY OF NORTHAMPTON
Lot:-001
Pennit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0508
Project# JS-2001-0875
Est. Cost:$2400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: DAVID NUNEZ 128305
Lot Size(sg.ft.): 16335.00 Owner. DECAROLIS VITO O
Zoning: URB Applicant. DAVID NUNEZ
AT.- 105 NORTH MAIN ST
Applicant Address: Phone. Insurance:
41 BRIAR HILL RD (413) 268-3395
WILLIAMSBURGMA01096 ISSUED ON.•11120100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE PORCH 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 Deaartment 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 11/20/00 0:00:00 1175 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo