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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(street/ci ty/s-taie/a P)
do hereby certify, under the pains and penalties of per3ury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Instuance 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) (Insuran(--Company/Policy Number) (Expiration Date)
+r.
(Name of Contractor) (insurance Compairy/Poky Number) (Expimdoa Date)
(Name of Contractor) (Inntranc-- Compau•/PoL cy Number) (Expiraton Dale)
(Name of Contractor) (Lnsuiance Company/Policy Number) (Expiration Date)
(attach additiocal shot ifnoocssuy to include iaf"mition pertaining to all occdradof3)
( ) I am a sole proprietor and have no one working for me.
{ I am a home owner perforruing all the work myself.
NOTE:plcaac be aware that wb:Uo hocnco%mcr3 vbo cmplay perori to do m iE1zn Luc oa or rrpair work on a dvtlling of
not more than throe units in which the homoowncr rmdcs of on the pvun s xMi'tcnant thatito arc oot Ccoff2Ily oomidacd to be
employcr3 under tha woticn'a=npaasatioa Act(GL152,ss1(5)�applicabcn by a hotneoRncr for a Lecnsc or permd tnay evidence tho
legal status of an omployoc under tho Wockcet Compemarion AcL
I understand dDd a copy of this rtucmcat may be forwarded to tho Departnmi of Iodudrial Aecidm&Offioo of Insvrsnoe for tlm
covaNge verification anal that failure to v-,a=00%e go ut d s4ctioa 25A of MGL 152 can lead to tho imposi -of crimin-sl penalties
consisting of N fine of up to S1,500.00 and/or impri5o of up to orx ycsr and civil peaaltics in the form of a Stop Work Ocdtr and a
fins o(:S I "day igpitr1 mc-
For dcputi use only
permit Number
Lot#
Si of Liccnsec/pertnittcc e
SECTION 8 =CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
leg sre �A mm wementContrcto s Not Applicable ❑
m
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...... ❑
rom Owne�� -xempt�on
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" ifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, St e and Lo I onin La s and State of Massachusetts General Laws Annotated.
Homeowner Signature �.
SECTION 5-�IIESCRfPTI0Nx0�PROPOSED WORf(3[check allapplicablej
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: u't'yDUc�()S•
Alteration of existing bedroom Yes y/No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes °� No
Plans Attached Roll ❑ - Sheet o
6 .1f ,'ew MffSe 5 d,o ;atlditiorft ezistin" housin' :-co'm lete t i f'ollowin `:
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 AGENTbR 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
OL ��)Lt c eZf C�s 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 th pains and penalties of perjury.
C &U -C� (G E:a L'L1
Print Name
Signature of Owner/Ag t Date
Section 4.
ALL INFORMATION MIDST 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 ver 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 V 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 V
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
f13 je
ding Department
12 Main Street Room 100
r f � ampton, MA 01060 7-1240 Fax 413-587-1272
ST UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION>
This section3to beFcomfil"eted by'office
1.1 Property Address: IN
//
r �E �4 Mapes g Loth t1it
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L o rz 1/ye AA t� to Zonea Overlay D stw tct Y
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El"St. Distract CS Dsir�ct
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name( int) Current Maili Ad ress:
�-" 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 ermit applicant
Building I (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;.
" BP-2003-0260
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ivck '3S- F° CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2003-0260
Project# JS-2003-0458
Est. Cost: $1300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor_
Lot Size(sy. ft.): 17641.80 Owner: ROLLINGS ANDREW
Zoning: SR Applicant: ROLLINGS ANDREW
AT. 949 RYAN RD
Applicant Address: Phone: Insurance:
949 RYAN RD (413) 584-0292Q
FLORENCEMA01062 ISSUED ON.9113102 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 9/13/02 0:00:00 438 $25.00
212 Maip Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo