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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORK-ER'S COMPENSATION INSURANCE ATTIDAM
I,
(li censeelpermi tree)
with a principal place of business/residence at:
(phone-#)
(streeUci ty/Stalrhi p)
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 Dale)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workel's compensation policies:
(Name of Contractor) (Insurance Compauy/Poticy Number) (Expimboa Date)
(Name of Contractor) (Insurance Company/PoLcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additional ahcet ifncccuiry to inctude information pertaining to all oD'uadors)
( ) I am a sole proprietor and have no one work:ng for me.
.�f I am a home owner performing all the work myself.
/ NOTE:ptcasc be aware that whilo hoarowvcrs who cmplay perz to&mamicaIn;axrstructioo or repair wvric on a dwelling of
not more than throe unit to Ai ich the homoowncr maiden or oa the Qouads appurtenant thane arc not Ccncrnlly ooasidcrcd to be
employers under tha veorkcces oampc=tioa Act(GL152,zs 1(5)),application by a homcow=for a lions,oc permit may evidcaoe the
]cgat omw of an employer under the Workcec Compoosation AcL
I undcntand that a copy of this ctatcmmi may be forwarded to the Dcpartnxat of Indust i al Amdcm&OfSoo of I—V—Dco for the
coverage verification and that failure to secure coverage under scetioa 25A of MGL 152 can icad to tbd imposition of criminal penalties
000lbting of a rme of up to S1,500.00 and/or imprisoamca of up to one year and civil pcnaltia in the form of a Stop W met Order and a
firm of s 100.00 a day against tna
For dcpartmc�u1O only
permit Number
/ Lot#
MaO
SiPab=of Liaansee/Permi e
i
SECTION 8-CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Ree ntered Him m�r"�vement'Contractor =1 M. 7 f Not Applicable ❑
. c`h'xr, ya»'a�u..s pp
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...... ❑
[A:54,f H,6m Owner JM, ;V6011
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 Loc ytfc s and of Massachuse acral Laws Annotated.
omeowner Signature —
SECTION "DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Sidin Other[ ]
Brief Description of Proposed Work: r,� ' ;� �• ` '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a, ff`.New house and or.. dd�t�on'to`existing=tiou"sing,econloWte h6,46116*14k:
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
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
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 �-"
Signature f Own /Agent Date
,i•
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
p 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:
i.
( of Northampton
i ing Department
V
21 Main Street
oom 100
�Ir
pr
tha pton, MA 01060
GlNSp�
9UM� 'tdIR 7-1240 Fax 413-587.1 272
Ottaer Specify , «
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
X1.1 Property Address: This section to be completed by office
Map Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) -- Current Mailing Address:
Telephone
Signature
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 permit applicant
Building 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
_ M
i w L :n BP-2002-1162
GIS#: COMMONWEALTH OF MASSACHUSETTS
4' . CITY OF NORTHAMPTON
Lot:-001
Permit: B u i I d i nil
Category: BUILDING PERMIT
Permit# BP-2002-1162
Project# JS-2002-1866
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(ss . ft.): 15028.20 Owner: LEBRON FELIX
Zoning:URA Applicant: LEBRON FELIX
AT. 143 DEERFI ELD DR
Applicant Address: Phone: Insurance:
143 DEERFIELD DR
NORTHAMPTON MAO 1060 ISSUED ON.6125102 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE/REPLACE EXISTING WINDOWS,
ROOFING & 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 6/25/02 0:00:00 9892703360 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo