18C-105 (2) I
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9 �t i ° / / asaAChnsctta _ •
CaW DEPARTMENT OP BUILDING INSPECTIONS , ° ` i = '
212 Main Street • Municipal Building
Northampton, Mass. 01060 I•11' s
W O RICER' S COMPENSATION INSURANCE AFFIDAVIT
1 -, c .,, c7 e,..--v-t..A. y. ___ 6
(licenseelpermrttee)
with a principal place of business/residence at:
y ° - t ch � . o y 0 .
��� � e � �'�- (phoney#) .3 > — ‘ ..� A S
(street /city /statelap)
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:
/)/y),,,,, 4,1).....Y 00,3,?2 cc 6 , .......,,,„,_ L ,____,...
(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 workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
r .
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additim'l short ifnoccssary-to include information pertaining to all contractor)
( ) I am a sole proprietor and have no one w orlting for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that while homeowners who employ pezoni to dj triaintcaanc , consfruaion or repair work on a dwelling of
not more than three units in trench the homeowner resides or oa the grounds appurtenant thereto arc oot generally oomidered to be
employers under the worker oanpersariea At (GL152,s1 1(5)), application bye homeownis for a Gee se oc permit may evidence the
1eg2.1 atan,a of an employer under the Worker's Compomalion Act_
I understand that a copy of this atatemcnt may be forwarded to the DepertmcoR of Industrial Accident? Offioo of 1nsrranoo for the
coverage vctificaiioa and that failure to secure coverage under section 25A of MC1L 152 can lead to the imposition of criminal penalties
oomisting of a fine of up to S1,500.00 and/or imprisocrut of up to one year and civil penalties in the form of a Stop Work Ordc and a ,
find of S100.00 a day against me_
For degar ufe Only
0 e- .- Permit Number
Map,{ Lot 4 •
Signa 'ttee late
y
SECTION 8 ;kCONSzTRUCTION.SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
n„m. r �.<. ; i f :ur + "g^ r . : -1'110440 {,,, "'' f Cy r ( a
�'tg'�"ered Hbme °Im rovement Contracl"o
P � .�.� �K ..,.� ' �.. .�,_ ...I Not Applicable ❑
Com.an Nam.' Registration Number
`7 C - ~ �J.�zGern ✓Yl (0;3.4_1 --- E> .—
Address Expiration Date
Telephone , Y 75
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 attic
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
•,:,ou Inem 'n _ 1,1A
The current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two(2) famil
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act
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 ther
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 In
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" ce ifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State a Local Zoning Laws and State of Massachusetts General Laws Annotated.
k Homeowner Signature ?e,"1.44(,,Cee.-1,64
SECTI N ' DESC PT N O PROPOSED ►YORK check a1I a • •licabl {
. -Z* 1L4t u4 ,.i,Ar ., ,,.,y,�ry° ry Ew As qw. i4n4. •NF. +,3fl3 eRd+aiCtlll ,k _.. .�x.,t., , a§,. �, hR'�wvti
•
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors '
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ter Other [ ]
Brief Description of Proposed Work: d.„./.. -- r y f � _„ r • ,
Alteration of existing bedroom Yes No Adding new bedroom es No
Attached Narrative Cl Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
0 IfiNeWilid isetanti or " edition to ezisti rig'.housing; comp"lretetht: dtloWi it
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 OWNERAUTHORIZATION - TO, BE COMPLETED WHEN
OWNERS,AGENTOR CONTRACTOR,APPLIES ' rOR'BUILDING PERMIT
I, ,e .ice SA 4 Ge , as Owner of the subject proper
hereby authorize to a c -
my beha , in all matters relative to work authorized by this building permit application.
l
412-e-44d-et_
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.
Signed under the pains and penalties of perjury.
Print Name
acv
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:
•
� 1`, jj L' ' _ v of Northampton , . r
' ` - ' �� i din Department
j j I' � 212 Main Street S • . lg
U L JAN 2 2002 ! ! ` Room 100 4 ` . '� t
orth mpton, MA 01060
;- 3 -5 7 -1240 Fax 413- 587.1272otSite P
,-.- 1 _ k , � g a 'sib �m �, q
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to)be completed by
1.1 Property Address: -
F � �E s �� six
/ Map Lot - 'Unit t
• m4 ,
V it o. *wry
--° Zone 'Overlay�Distrct
Urn St. District CB D
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Ow- of Record:
- � /1 / / / i i ijIIR
A l
Name ( ,,,R) Current Mailing Address:
i
��f�✓ c� /GZG�G{ Telephone. _ b 5 t� [/
X Signature / O
2.2 Authorized Agent: �/ ilo �/
L, A r r y p43 t vF `i''7 1= .,r, --„ , p G -'Q y''Y' r� � o`d'd - _
Name (Print Current Mailing Address: r
Signature / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ` " / I-41- e (a) Building Permit Fee
2. Electrical 4 ' - ° � "�"'"` (b) Estimated Total Cost of
�,
"750 d ° Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number ,j . f�-s
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r
"51 GLEASON RD BP- 2002 -0613
GIS #: COMMONWEALTH OF MASSACHUSETTS
Mau:Block: 18C - 105 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: replacement windows /siding BUILDING PERMIT
Permit # BP- 2002 -0613
Project# JS- 2002 -0955
Est. Cost: $13000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq. ft.): 7143.84 Owner: FOX LUDMILLA & ALEXANDER HAUSS
Zoning: URB Applicant: Larry Paquette
AT: 51 GLEASON RD
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527 -6375 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:1/2/02 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & SIDING
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 1/2/02 0:00:00 2958 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo