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DEPARTMENT OF BUILDMG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INS AFFIDAVIT
I,
(li permittee}
with principal place f b e residen at
(phone#)�
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:
(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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sheet if nocenary to include inf«m,tioa pertniaing to all coa rl d )
( ) 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 whilo homeowners who employ persons to do maia�wnsh-1=on or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the groin appurtenant tb=w arc not generally 000ndered to be
employcra under the wmita's compensation Act(GL152,ss 1(5)),application by a homeowner for a license or Permit may evidcnoe the
legal stabs of an employer under the Wodcar's Compemation Ad.
I understand thst a copy of this statement may be foa"warded to the Dcputnr of Industrial Accidarts Offioa of Insruance for the
coverage verification and that failure to secure covemp under section 25A of MOL 152 can lead to the imposition of criminal Penalties
ooasisting of a fine of up to S1,500.00 andlor imprisownexit of up to one year and civil penalties in the form of it Stop Work order and a
firm o(5100.00 a day against me.
P For"dq,srt ntaw uao only
\/ Permit Number
Mai Lot 4
Signature of cansee/Permittee
w
�
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not ApplicableXR
�
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §2SC(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.
01, 'took
The current exemption for"6oueovmnem~was extended toinclude one(1) or mvo(2)fan`Uieo
and m allow such homeowner to engage uo individual for hire who does not possess ulicense,
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 buildini!permit.
As acting Construction Superviso your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit ixissued.
Also bc advised that with reference to Chapter l52(Workers' Compensation) and Chapter 153 (Liability of Employers tu
Employees for injuries not resulting iu Death)of the Massachusetts General Laws Annotated,you may be liable burpexmoo(o)
you hire to perform work for you under this permit.
The undersigned'^booueovmzo"certifies and assumes reoponu8bUityfovcooqpliuooe with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State oC Massachusetts General Laws Annotated.
Homeowner Signature
•
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
r
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Rip two layers existing and replace with archi tectual shingles
Alteration of existing bedroom -Yes XX No Adding new bedroom Yes Noxx
Attached Narrative❑ Renovating unfinished basement Yes XX No
Plans Attached Roll ❑ - Sheet❑
60..f.,< w...'0" itNtt""to"" i h. a t► f' 1° Me
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
Diane Greenwood as Owner of the subject property
hereby authorize Stephen Chaput to act on
my behalf, in all matters relative to work authorized by this building permit application.
10/18/2000
Signature of Ownerj 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.
Diane Greenwood
Print Name
October '
Signature of Owner/ ent Date '
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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 93X130 93 X 130
Frontage 93 93
Setbacks Front 32 32
Side L: 20 R: 20 L: 20 R: 20
Rear 63 63
Building Height single story
Bldg.Square Footage 1656 13 % 1656 13%
Open Space Footage %
(Lot area minus bldg&paved 10,106." 82 10,106.5 82
parking)
#of Parking Spaces two two
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO XX 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 x— 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 xx
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No Y
IF YES, describe size, type and location:
City of Northampton % .
Building Department
212 Main Street
Room 100
Northampton, MA 01060 E
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
1
This section Jo be com
.1 Property Address: I� " bY offi e
20 Alamo Court dot
Florence, MA, 01062 ions, ` '���% ' O�rerla
7 �,. wr
Elm St.District rie� ;
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Diane Greenwood 20 Alamo Court, Florence, MA. 01062-3423
Name irt) Current M ilin Address:
411 586-5486 _
!�' y� i e-,'e, Telephone
Signature
2.2 Authorized Agent:
20 Alamo Court, Florence. MA, 01062-3423
Name(Print) rrent Mailing Address:
413 586-6474 or 586-5486
Signature Telephone
SECTION 3- EST N TR T N COSTS
IMATE
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Roof Shingle 2, 500.00 (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 Only
Building"Permit.Number: Date Issued;
Signature:
Building Commissioner/Inspector of Buildings Date
IM
20 ALAMO CT BP-2001-0409
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofin BUILDING PERMIT
Permit# BP-2001-0409
Project# JS-2001-0686
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 12283.92 . Owner: GREENWOOD DIANE
Zoning: URA Applicant: GREENWOOD DIANE
AT: 20 ALAMO CT
Applicant Address: Phone: Insurance:
20 ALAMO CT (413) 586-5486 O
FLORENCEMA01062 ISSUED ON.10 118100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 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 10/18/00 0:00:00 1866 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo