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35-041 (2) 60l WIKo%„rs w . �O e�ek V r �f s _`\�� .. fib.• c q- f• 0�� PTO aSERCIIRSrtlS DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT L W7 (Ii ensee/permittee) with a principal place of business/residenc�e/fat: 3 5--So. 51- �o . rye Gtr /¢ (phone#) /3 S'4—_30 7 city/stafe/rip) do hereby certify, under the pains an 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) (anach additional sheet if necenuy to iacludc information petta.ining to all 000tradors) ( 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 wbilo homeowners who cmplay pcnons to do m&jmeasaor,coashuwoo or repair work on a dwelling of not more than throe units in which the hornaowner resides or on the grounds appurtenant thereto art not generally ooandered to be cmployca under the wrorku'a compensation.Act application by a homeowner for a license or permit may evidence the legal status of an employer under the Worker's Compensation Ad. I understand that a copy of this rtatemeni maybe fmwanied to tho Dtpertacat of Iodrutrial A=dca&Offroe of Irrarrrsnoe for the coverage verification and that failure to acatre coverage under section 25A of MOL 152 an load to the iazposid0a of criminal pcnakies comisiing of a fine of up to$1,500.00 and/or imprison of up to one ytar and civil penalties in the form of a Stop Work.Order and a firm of St00.00 a day against ma. For dgrartW40tal use only _ Permit Number Map# Lot# Sr f Licensee/pe ttee t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor, Not Applicable 0 I Name of License Holder : � KO CS O ; ! o License Number 0 f S2 3 W I O Addres Expirat on D to �►3 ��S-3Q3 Signature Telephone Not Applicable [9' 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 he building permit. Signed Affidavit Attached Yes....... U, 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 SE C1105 I 5 ED WRRK(gheck @11 applicabl e New House ❑ Addition ❑ Replacement Windows Alteration(s) Fl`� Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes t/No Adding new bedroom Yes ''� No Attached Narrative❑ Renovating unfinished basement Yes tNo Plans Attached Roll ❑ - Sheet P re Mwinft ... 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 OWCONTRACTOR-APPLIESiFOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aut rized by this building permit application. Signature of Owner — Date I, as Qwp*% Authorized Agent hereby declare that the statements nd information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and enalties of perjury. 1-4 ti Print Name` Signature of Agent DA 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: 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 L-"� 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: '-City of Northampton uilding Department 'f 212 Main Street Room 100 N rthampton, MA 01060 Of BU1tolNG I N41 -587-1240 Fax 413.587-1272 NORTNFtMPTG"l 0106Q APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-S;.ITE',INFORMATION _ 1.1 Property Address: //q� U� a� . f�/ b A/ %y El"rti Sr strict fix, C [>Istrlct / SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: -- / l/ D f- ,TGAh �1L-111 -7 Na—m lint) Cur re i/M)Iing �es�: Te ephone Signature 2.2 Authorized Agent: Names) Current Mailing Address: Signature Telephone GcrTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �® (a)Building Permit Fee f � e r 2. Electrical �v (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) / �v Check Number This Section For Official Use Only Building Permit Number Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2001-0277 APPLICANT/CONTACT PERSON TIMOTHY MORGAN ADDRESS/PHONE 35 SOUTH MAIN ST (413)665-3039 PROPERTY LOCATION 71 SYLVESTER RD MAP 35 PARCEL 041 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid !2 Typeof Construction: INSTALL 2 WINDOWS&2 DOORS(EXTERIOR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 054896 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 Signature of Buildin fficial 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. • __......Q-- --.:�____.. s,. "� - �,. ., ,, .. `., 71 SYLVESTERRD BP-2001-0277 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-041 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category'Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0277 Project# JS-2001-0448 Est.Cost:$11000.00 Fee:$50.00 PERMISSION IS.HEREB Y GRANTED TO: Const.Class: Contractor: License: Use Group: TIMOTHY MORGAN 054896 Lot Size(sq.ft.): 52272.00 Owner: AVEDON MYRA&JEAN FRANCES Zoning:RR Applicant. TIMOTHY MORGAN AT. 71 SYLVESTER RD Applicant Address: Phone: Insurance: 35 SOUTH MAIN ST (413) 665-3039 SOUTH DEERFIELDMA01373ISSUED ON:9/15/00 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 WINDOWS & 2 DOORS (EXTERIOR 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: y��y/p�h� House# Foundation: Final: Final: 1-ZAl. I t Rough Frame: L,�X 3~�fJ Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: ©k T—`off b ,©O Final: Smoke: Final: `g THIS PERMIT MAY BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc)l Si nature: Fee Ty- e: Recei t No: Date Paid: Check No: Amount: Building 9/15/00 0:00:00 736 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo