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35-014 f �-tnn�+nT 0 ��g Crzf� oaf �ctz-#f��il�tniT 9 B asaachnsctill _= m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT C3 Z)7.11, (Ii cen ser�permi ttec) with a principal place of business/residence at: `--z C S CQ-4 l( ��tl — --(Phone;#) `1 '_"(2 `7 (Stmze uci ty/statrJzi P) do hereby certify, under the pains and penalties of perjury, that. ( ) I am an employer providing the following workers compensation coverage for my employees working on tivs job: (In-s>_uancc Comp)') (Policy Number) (Expiration Date) APO* ( ) I am a sole proprietor, general contractor or homeolwvner (circle one) and have hired the contractors listed below«-ho have the following worker's compensation policies: (Name of Contractor) (111surancc CompaEy/Policy Nulubcr) (Expiration Date) (Name of Contractor) Qns-uance Company/Policy Number) (Expimuon Date) (Name of Contractor) (Insuranc; ComJ213y/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (P-Ma'd1 addr60021 Sh6et tf n6CeSi to[nC}UdC LafOrtnatr oft pclta:Il:II�LD e.t]f rndon) O I am a sole proprietor and have no one worlang for me. ( ) I am a home owner performing all the work myself. NOTE:plcnsc be awarc that while bomcoAncts who cmplcy peters w&aixicaaac, coastrudioo or repair work on a dwelling of not More than throe units in which t d homoowwr made=or on t5e gvands zppurkniat therfto arc no(gweralty ooa:idcrcd to be mploycra under the wariccr's oomp St tics Act(GL152,ss l(5)�application by a homeowner for a ticcase cc permd may ngdenoc the legal datua of an employer under the Wociceeg Compoosatioo,tit t I understand that a oopy of this ctatemcui may be forwarded to the Depertmc ca of Ind.sstrial Adea&O>�oe of Iusius000 for the oovaigc vaificatioa and that failure to&==coverage/alder section 25A of MGL 152 can lead to the iutposition of-=-Il paialtica oomisting of a fine of up to S1,500.00 and/or impraonmcrA of up to one year a0d av l pcnaatia in the form of a Stop Work Order and a find of S 100.00 a day against me_ For dcpa tratnW use oaly Permit Number Map'! Lot# Signature of Liccnsee/perrnittee 3 e SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: '0 4 n. �C C��'!! yWa 1�6 OC7 9 L1,?k License Number G(arts a Address Expiration Date Signature Telephone Mau �( �E -; Not Applicable ❑ 0S� e2 Company Name Registration Number 6 Address Expiration Date Telephone �� 7 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. igned Affidavit Attached Yes....... . No..... a FF, 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 00%, �WZCTION 5- DESCRIPTION OF RROROED WORK(c eck'a I applicabi e New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other [ ] Brief Description of Proposed Work: a4Z, A,9- kl* 11,U S-� p lrG�tV� iuC Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ FCl 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 SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, SCZTi t-,C tOA Li(6— as Owner of the subject property hereby authorize �3 O 1�s �z�c GC_ to act on my behalf, in all matters rela tive to work authorized by this building permit application. SC /vl, �� L�l ) /Co 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. ooibS under the pains and penalties of perjury. wA-1 Print Name Signature o wner gent 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 li-z o L N 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: Q 4ity of Northampton 5 ilding Department _ 212 Main Street EPZ OF BIl's ;4c,,1�iSPE�u hS Room 100 f,U orthampton, MA 0106V phone 413-587-1240 Fax 413-587-1272 a APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION This section t[t be completed,by 1.1 Property Address: S 1 2 s Map I*ot #knit one prrerlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: : c- r�,�%D ame(Print) ,/�• Current Mailing Address: Telephone Signature ':S4 y' 0 9 2.2 Authorized Agent: C3 �c3 R �-vc w,,,.� 3 C SQ ,�L Cu- cam. 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) 00-0 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Comm iss loner/Inspector'of Buildings Date File#BP-2000-0858 APPLICANT/CONTACT PERSON Robert cep ADDRESS/PHONE 36 Service Center (413)584-1224 PROPERTY LOCATION 185 WEST FARMS RD MAP 35 PARCEL 014 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled-out Fee Paid ��F 7 '- Typeof Construction REPAIR STEEPLE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 034783 3 sets of Plans/Plot Plan THE LOWING 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 Commission Permit from CB Architecture Committee �_� . GD Signature of Building O cial 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. 185 WEST FARMS RD BP-2000-0858 CIS#: COMMONWEALTH OF MASSACHUSETTS 1400k1W.Block: 35-014 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category'Non structural interior renovations BUILDING PERMIT Permit# BP-2000-0858 Project# JS-2000-1602 Est.Cost: $7000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Robert Reckman 009498 Lot Size(sq. ft.): 71 00.28 Owner: MCDANIEL SCOTT Zoning: SR Applicant: Robert Reckman AT. 185 WEST FARMS RD Applicant Address: Phone: Insurance: 36 Service Center (413) 584-1224 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:416100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR STEEPLE MOXOST THIS CARD SO IT IS VISIBLE FROM THE STREET nspector 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 4/6/00 0:00:00 9104 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo t 3 a r r 185 WEST FARMS RD BP-2000-0858 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 35 -014 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2000-0858 Project# JS-2000-1602 Est. Cost:$7000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor. License: Use Group: Robert Reckman 009498 Lot Size(sq.f1j: 7100.28 Owner: MCDANIEL SCOTT Zoning: SR Applicant: Robert Heckman AT. 185 WEST FARMS RD Applicant Address: Phone: Insurance: 36 Service Center (413) 584-1224 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:416100 0:00:00 TO PERFORM THE FOLLOWING WORK:REPAIR STEEPLE 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: 0 If G-/,�•o o THIS PERMIT MAY BE REVOKED BY THE CITY O NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS..�/ / Ar- Certificate of Occu anc Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/6/00 0:00:00 9104 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo