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35-018 (3) OQ�t PTO $e � �I�Slrirrlatt8ettfr . DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT (licenset°Jpermittee} with a principal place of business/residence at: (phone#) (street city/staldzip) 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 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) (`3-ch addi6ocal sboct ifnecc—Y to include infottnarioa pertaining to all ooatrncfots) ( ) 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 h0mo0w=3 who employ persons to do mainzrnaace,coosmiciioa or rcpau work on a dwelling of not more than three remit in which the bomeowncr resides or on the grounds apptutmant thetcto sn not generally coandered to be employers under tbo work ces c ompens4on Act(GL152,sa 1(5)),application by a homeowner for a 6cen se,cc permit may evidcnoc the legal status of an omployx underthe Worker's Compemstion AcL I undaatand that a copy of this etatemcca maybe forwarded to the Depwtmma of Industrial Acci&n&Offcoo of Iaainnoo for tbo cover age verification and that failure to secure covemgo under section 25A of MOL 152 can lead to the imposition of etimiaal penalties consisting of a fine of up to S1,500.00 and/or imprivo of up to one year and civil peaatties in the form of a stop Work Order and a fum 0(5100.00 a stay ag¢irut me. For dg»�1110 O°'y Pcrmit Number Lot# Sipauure of Licenseelpermittee e 01,0N$ SERVI"S 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone {g- Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION Q�1lVf)RKERS',.Cf)MPENSATI N 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. 'gned 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 ION D. O 1 the a b e New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing V( Or Doors 6t( Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[V [ ] Brief Description of Proposed Work: �� 1 Alteration of existing bedroom Yes__L No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll❑ - Sheet❑ a. Use of bui 'ng : One Family_ Two Family Other b. Number of rooms ' each family unit: Number of Bathrooms c. Is there a garage attache . d. Proposed Square footage of new c truction. Dimensions e. Number of stories? i f. Method of heating? 1 Fireplaces or Woodstoves _Number of each g. Energy Conservation Compliance. check Energy Compliance form attached? Type of construction i. Is construction withi 0 ft. of wetlands? Yes No. Is cons tion within 100 yr. floodplain Yes No J Depth of bas ent or cellar floor below finished grade k. Will b ' ing conform to the of and Zoning regulations? V Yes No . I. con Tank City Sewer Private well City water Supply SECTION 7a,OWNER AUTHORIZATION »TD BE COMPLETED WHEN OWNERS AGENT OR ONTRACTOR APPLIES FOR BUILDING PERMIT o La. 1 C,n as Owner of the subject property hereby authorize rai e,;(ncr to act on my behalf,iin' all matters relative o work authorized by this building permit application. Signature oT6wner 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. igned under the pains and penalties of perjury. Ghi o Cha_t:, Print Name Signature of 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 o S CtG1R°_ Frontage Setbacks Front Side L: R: L: R: Rear Building Height /a r Bldg. Square Footage / % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces a 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. V1,ere any proposed changes to or additions of signs intended for the property ?YES— No IF YES, describe size, type and location: .r 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 SEC TION:1-SITE INFORMATION 1.1 Property Address: `his�er�o � �crrlplet d-byff � � � Eimt;St D€srief. `tSfstrict . SECTION 2- PROPER'TY©WNER HIP/AUTHORIZED.AGENT 2.1 owner of Record: 1_ ame(Print _ Current Mailing A ess• Telephone Signature 2.2 Authorized Agent: sal S;o iti tindC� Name(Pri ) Current Mailing Address: Signatur Telephone StOGN A EDiONSTflUCTION Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building _� (a)"Building Permit Fee 2. Electrical F (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 Thls Section For Official Use On uilding.Permit Number: Qate Issued: Signature: Building Commissioner/Inspector of Buildings Date 132 WEST FARMS RD BP-2001-0632 GIs#: COMMONWEALTH OF MASSACHUSETTS "'Map:Block: 35-018 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category'ROOFING/REPLACE WINDOWS BUILDING PERMIT Permit# BP-2001-0632 Project# JS-2001-1139 Est. Cost: $12000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sa. ft.): 23348.16 Owner: CHAN CHID Zoning: SR Applicant: CHAN CHIO AT. 132 WEST FARMS RD Applicant Address: Phone: Insurance: 48 CHARON TERR (413) 538-5796 O SOUTH HADLEYMA01075 ISSUED ON.1 1121010:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF & INSTALL SIDING & WINDOWS 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 Denartment 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 OCCUDancy si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 1/12/010:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo " o F a, • k k L z 666 ;3 f 4 S� C ' 4 y: �� .. S BP-2001-0632 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Block:35-018 CITY OF NORTHAMPTON Lot: -001 Permit: Buildin4 w Category:ROOFING/REPLACE WINDOWS BUILDING PERMIT Permit# BP-2001-0632 Project# JS-2001-1139 Eg:Cost:$12000.00 .. Pee: 25.00 PERMISSION IS HEREBY GRANTED TO: Coast.Class: Contractor: License. Use Group: Lot Size(sq.ft.): 23348.16 Owner: CHAN CH10 Zoning:SR Auplicant. CHAN CHID AT 132 WEST FARMS RD AnitlicadtAddress Phone: Insurance 48 CHARON TERR (413) 538-57960 SOUTH-HADLEYMA01075 ISSUED DN:11121010:00:00 + " TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF & INSTALL SIDING & E WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plunx*ng Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire DwartmeatN Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:. I t THIS PERMIT MAY BE REVOKED BY TH ITY OF NORTHAMPTON UPON VIOL TTI N OF ANY OF ITS RULES AND REGULATION Certificate of Occupancy, si nature: Fee Tvae: Receiut No: Date Paid: Check No: Amount: Building 1/12/010:00:00 Mn $25.00 M i 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo