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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1,
Oicensee/permittee)
with a principal place of business/residence at:
(phone#)
(street/ci ty/star edzi p)
do hereby certify, under the pains and penalties of peoury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O 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) (In,,uranc-- Company/Policy Number) (Fapumdon Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(anadt additio¢al sheet ifnrcu to iac}ude information pertaining to all coatractors)
( ) I am a sole proprietor and have no one worldng for me.
d I am a home owner performing all the work myself.
NOTE:plea=be aware that wfrilo homco«vcn who cmplay pcnoas to do fn corlstr ioo or rcpau work on a dwclag of
not morn thao thrro units is which the homeowner sides or oa the pounds zppttrtenant tba do arc cot gcnmily coaridcrcd to be
employem undo the worker's compensation Act(GL152,s3 1(5)),application by a homcow na for a license cc permit may evidence the
legal rtahu of an amployor under tho Wor$ode Compemation Act_
I undmund that a copy of this eatemeat may ba forwarded to tho Depart wed of IohLihid Aocidw&Ofhoo of Inver*noa for tho
coverage varifitxtioo and that fail=to&tarn covaago under suction 25A of MGL 152 can lead to tba impos ioa of criminal pcaalties
eom suing of a froe'of up to S 1,500.00 and/or impriso:nixat of up to one year and civil pc�atlia in the form of a Stop W orlc Otdc and a
fi=n of 5100.00 a day against roc
For dcputn�use ocly
permit Number
t a I pW Lot#
4 _ Si f LicensedPermittee 2
Yd r
eA
11r t
SECTION8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
. �g Not Applicable ❑
Rey sere"' dome°I m r vem`ent'Con racto �, - �„ � £f
Company Name Registration Number
Address Expiration Date
Telephone
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
�.�..E-_H;ome�Owne:�r�Xempt�on
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
� , H,�,� �
SECTIONS DESCRIPTIONOFaAROPOSED WORK'checkall.a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitions New Signs [ ] Decks [ ] Siding [ ] Other [ ]
c N)
I Brief Description of Proposed Work:_'1 0-Q P• G11 rm iw� q�/) W �� Stu�-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet o
ha lf.<I er+v h t)SVb door addition fo e�ci'stingLLhous�ng cotriptete th"e foll'owin
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
SECTION 7a=,.OWNER'.AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS'-AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
P int Name
r
Jed �
Signature W 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:6 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�s,
IF YES, describe size, type and location:
n ( .1 i of Northampton
1 u ing Department
i JUN 2 0 200 1 Main Street
oom 100
DEP?Of BU1l.DING INSPfCTI g)rtha pton, MA 01060
ynaTuatApttlht 1240 Fax 413-587-1272
Qt1et�Sl� '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR�EMOLISH A ONE)OR TWO FAMILY DWELLING
SECTION 1 - SITE LNFORMATION
MThis section to be completed�by office
1.1 Property Address: "
C� g S'S, o f ��– Z no a Overta bist �ct �
Elm St.,District CB District s
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�JaS e. PajV 210 � crQ,� l—cad` D►'
Nam (Print) — Cu ent Mailing Address:
t'L o r -e.6- c 2 (h r-)- o16 6 �
Telephone f /
Si nature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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
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 Onl
Building Pe rmitNumber._���/� Date Issued:
�U
Si�gnatu e
Build�ngCo'mmisstgner/Inspectorof'Bu�ldings Date
File#BP-2001-1084
APPLICANT/CONTACT PERSON ALVARDO JOSE ANTONIO&YOLANDA
ADDRESS/PHONE 244 ACREBROOK DR (413)584-6363 Q
PROPERTY LOCATION 244 ACREBROOK DR
MAP 29 PARCEL 335 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out
Fee Paid
Typeof Construction: REMOVE CHIMNEY&WOODSTOVE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE LLOWING 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 Commissipp Permit from CB Architecture Committee
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.
�� BP-2001-1084
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-1084
Project# JS-2001-1909
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 10018.80 Owner: ALVARADO JOSE ANTONIO&YOLANDA
Zoning:URA Applicant• ALVARADO JOSE ANTONIO & YOLANDA
AT: 244 ACREBROOK DR
Applicant Address: Phone: Insurance:
244 ACREBROOK DR (413) 584-6363 ()
FLORENCEMA01062 ISSUED ON.61211010:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE CHIMNEY & WOODSTOVE
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 Type: Receipt No: Date Paid: Check No: Amount:
Building 6/21/010:00:00 4558 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo