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29-546 (6) of 'Xart 4aiurLIIIt M — ae �asaarhDSrtta m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AF'FEDA.VIT T-, (licenserJpermittee) with a principal place of business/residence at: (phone#) .Xf'331k (strc:Ucity/statd21p) do hereby certify, under the pains and penalties of pemiry, that: ( ) I am an employer providing the following worker's compensation coverage for my t employees working 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) (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 additional stied if neoe nxxy to include information pertaining to all coatr,d ) ( 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 wbile homeowoets who employ pasoas to do,,,aiatm."oc�constnution or repair work on a dwelling of not stole than three units in which tfie homeowner resides a on the groarxls appurtennra thereto are Dot generally,ooaskkred to be employers under the work="s compensation Ad(01,152,=1(5))�application by a homeowner for a license or permit may evidence the legal status of an employer under the Workeez Compensation Art 1 understand that a copy of this rLatemant may be forwarded to the Deputncni of Lx u ftiel Acciden&Office of 1n=vDCe for the oovaage ve ification and that failure to secure coverage under section 25A of MOIL 152 c=lead to the imposition of criminal penalties oomisting of a fine of up to S 1,500.00 and/or imprisomseci of up to one year and civil pemttia in the form of a Stop Work Order and a fins of S 100.00 a day against tae For dga1 use only Permit Number Map# ---Lot# Signature o )ic=see/permW= ACT COI ST- JCT1aN; ERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name nn Registration Number �t (fir "P ft IBC -G� Address Expiration Date �i Telephone ECIaN 16 YV3RICERS' CQMF�ENSATiQN IN5URANCE,AFt"t©AVIT(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. igned 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 S e of Massachusetts General Laws Annotated. Homeowner Signature / \ ti MAI OE New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ I Brief Description of Proposed Work: L !" k- Alteration of existing bedroom Yes No Adding new bedroom s No Attached Narrativp r_; Renovating unfinished basement PYes No Plans Attached Roll Li - Sheet❑ .r 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? 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 SE�Ti©N 7 -bWNER AVT ORI ATI 1N Ta GE GOMPLETI=I. WHEN V 11=j AG 1 T t} t f C� "1 t4G7' R 'PL fl BUMPING PERMIT W - t Gam! as Owner of the subject property hereby authorize to act on my b half in all matters relative I rk authorized by this building permit application. ignature of Owner Date S V as Owner Authorized nt hereby declare that the statements and information on the foregoing application are true and accurate, to s of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Date Signature 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 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 Perm it/Variance/Findiinng 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: — City of Northampton Building Department 212 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 SECT-10#1-SITE ,NF.ORMATION d 1.1 Property Address: f �x SECTIOiil 2,-PRQPERTY OY NERSHI ?? AUT: ORIZ D AGENT 2.1 Owner of Recor 6" 7 31 T,.&2t ame(Print) Current Mailing Address: W • Telephone Signature 2.2 Authorized Agent: G�;d ;�d v�cL ( - AIli Ik A, oloy 4 Name(Pri Current Mailing Address: C4 73 W Signature Telephone ,a ESTI AT CO TRUCTIOkco 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' Con' uction from 6, 3. Plumbing Bull ding„Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3+4+ 5) 0 ------ Cis ck rhber ThIs:S tf6n For Official US On B:ildin Permit Nrrtlaer gate Issued; ,Signore Date . Build�rrg Commissioner/1hspector of Buil lii i e#BP-2001-0704 I APPLICANT/CONTACT PERSON PRITCHARD DAVID r,1" 'n ADDRESS/PHONE 31 INDIAN HILL IJ a PROPERTY LOCATION 31 INDIAN HILL MAP 29 PARCEL 546 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Fi_lied o Fee Paid Typeof Construction: SHEETROCK&INSULATE OPEN CELLAR New Construction Non Structural interior renovations Addition to Existine Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan 2OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: +, Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation C fission Permit from CB Architecture Committee / L 49 Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. � R 1� 31 INISIAN HILL BP-2001-0704 GIS#: COMMONWEALTH OF MASSACHUSETTS a :Block:29-546 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0704 Project# JS-2001-0626 Est.Cost: $3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq. ft.): 15289.56 Owner., PRITCHARD DAVID Zoning.URA Applicant. PRITCHARD DAVID AT. 31 INDIAN HILL Applicant Address: Phone: Insurance: 31 INDIAN HILL FLORENCEMA01062 ISSUED ON.•2128101 0:00:00 TO PERFORM THE FOLLOWING WORK:SHEETROCK & INSULATE OPEN CELLAR POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings lnderground: 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 2/28/010:00:00 1204 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo