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29-297 OQ"�tiAMp�O $ GrxtLl Of Xart4antpton -ell ,� + �IassacElasctts'' vl _ DEPARTMENT OF BUILDWG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT AY 'Y (i ierminee) with a principa. ,place of usiness/residence at: Af C-111 ' .11 v 2> (phone#) S� 7- (st MWCity/staielup) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: 0 C: ;_20C J (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) (Attar additioaal sleet ifnecc=ry to include information pertaining to all ooatrn ) ( ) I 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 while homcowncta who employ pawns to do maadcain ce,construction or repair work on a dwelling of not mare than throe units in which the hotmowocr sides or oa the gcouads appurtenant ther+do are not generally coandercd to be employers under the tvorkees compeau4ca Act(GL152,ss 1(5)),application by a homeowner for a license or pcmit may eviden-the legal ctatua of an employer under the Workeet C.ompomation Act I understand that a copy of this ststemcat may be forwarded to the Dvwumwt of Industrial AoeibrmtY Offioe of Insrnanae for the coverage verification aad that failure to secure coverage under section 25A of MOIL 152 can lead to the imposition of criminal Penalties oomistatg of a fine of UP to 51,500.00 aad/of bmPriso�of up to ow year and civil penalties in the form of a Stop Work Order and a fmo of 5100.00 a day against ma. For dTx tmeoinl use oily Permit Number p_4Lot# Signature o icensedpe tree Late LAZO 1©t GflWSTRl1 'lat„5i �1t5 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone MMMM vim Not Applicable ❑ Company Name i,. J Registration Number Address Expiration Date Telephone SE1'}�Q �.VkORKERS'CtriPS# � t IURANGEIaAY1T;(M:G.I x.152, .. .. r-o .v,. 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 State of Massachusetts General Laws Annotated. Homeowner Signature ? Y i t a ).: , ,,.i - y, 3 i y3 � New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ • Sheet❑ 11 Mid 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 o �tyy7. rf+`lAtry.Y■[�r >*cl�# . sr wtiyyyy■N r!w .i33 0I'l ��lF',M`k�. PRMIT 1 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1 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 e C+l Signature of Ow r/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: '�w1114� 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 SEGTIQ I 1 Sll I INFORMATON' 1.1 Property Address: Yy JA SE1., 1IT�f tW1E111�"H � tAfaENT 2.1 Owner of Record: r &0 Ec1u � I?Na,",,V '4 I—Name(Prints Current Mailing Address: Telephone Signat re 2.2 Authorized Agent: l-r A 4 N ti/ I �t`'Y+t'�� y �t C"�?�y 1 .ytn � �%L� C �1` l °fJ Y e--, :4 °il- �.-- Name(Print) �T Current Mailing Address: Signatu a Telephone SCT[ON LSTIMAT,Ed� t1CTfON COSTS Item Estimated Cost(Dollars)to be al..1J OPJY, completed by ermit applicant 1. Building C °— ja) Building Pew nit4Fee 2. Electrical (b)Est' irriated Totai Cost of Gianstruction frarn 6 3. Plumbing Bu€Iding 0ermit F 4. Mechanical (HVAC) 5. Fire Protection 1 6. Total =(1 +2 +3+4+5) Checkurne �. , ' Thi +ctfd``: or Official Ui6.Oni 8 ,mid'€' g:lermltturrtr: Date Issued Buildnggrraissn, rinsp �rs pt .. s 120 BROOKSIDE CIR BP-2001-0635 GIs#: COMMONWEALTH OF MASSACHUSETTS ap:Block:29-297 CITY OF NORTHAMPTON Lot:-001 Permit: Buildinq Category:vinyl siding BUILDING PERMIT Permit# BP-2001-0635 Project# JS-2001-1142 Est.Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Grou- Larry Paquette 100679 Lot Size(sg.ft.): 14287.68 Owner: ANDREWS BEVERLY R Zoning.URA Applicant. Larry Paquette AT. 120 BROOKSIDE CIR Applicant Address: Phone: Insurance: 40 East Green Street (413) 527-6375 Workers Compensation EASTHAMPTONMA01027 ISSUED ON.1 116101 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING Aft 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 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 Tyne: Receipt No: Date Paid: Check No: Amount: Building 1/16/010:00:00 2662 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo