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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 T
WORKER'S COMPENSATION INSURANCE AFFAMAVTT
(li censee/permi ttec}
with a principal place of business/residence at:
(phone#)
(str>✓ctici ty/s�atr/Il p)
do hereby certify, under the pains and penalties of per3ury, chat:
( ) 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) (Exp mtion 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)
(attach additioail shoat if mccm ry to include iaforma:ion pertaining to all cvutmctors)
O I am a sole proprietor and have no one workng for me.
( ) I am a home owner performing all the work myself.
NOTE:ptease lx aware tfiat whilo homeotiixsz who cmplay parsons to do mx jat�coat rum oa or-pair work on a dwelling of
not more than three units in Which the honbowncr r=&-3 or on the grou5s appurtenant thacto arc no(wally ooaiidatd to be
employers under the wmk&s coagcm4oa Act(GL152,ss 1(5)�appticaboo by a homeowner for a liccisc cc permit may evidence the
legal stab"of an employer under the Workcez Cosvpemation AcL
I understand th:t a oopy of this slatcmmt may be for wnrd-ed to the Dc9artaim2 of Industrial Ac6dasty Offioo of I—noa for the
coverage va ificalion aid that failure to warn covcmgo und-r section 25A of MGL 152 can lead to the iruposifion of criminal pcialtics
consisting of a fine of up to S 1,500.00 and/or imprisoanxat of up to one year and civil pen&Wcs in the form of a stop Work Ord--and a
fum of s 100.00 a day against mc-
For dcpsrtnrr3al trio only
permit Number
Mapt Lot#
Signature of Licenseelpermittee e
. v
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�R m mrveme'it x. Not Applicable ❑
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...... ❑
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, S d Local Zoning La and State of Massachusetts General Laws Annotated.
Homeowner Signature '
SECTIONS- DESCRIPTION=OF PROPOSED WORKi(checkrall applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
-� � °� °completethefollowin�:
sa, IfNew�'house-and�oraddition to ezisting�Fiousirig':
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
here authorize to act on
7ignature alf, in all matter relative to work authorized by this building permit application.
0 ner 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 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
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:
r
My of Northampton
APR 2 2 2002 >>$ I !ding Department 0 x
s 12 Main Street r
Room 100
Nort ampton, MA 01060
-=� phone 413-587-1240 Fax 413-587-1272 Pta
t7t ,er�Spee:liy
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be�completed by offtceQ,
1.1 Property Address: �r
a
Zane Overlay'District>
- - ,
EImSt.'District C8 Dis3nct.
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�� /, , T I
Na (Print) Current Mailing Addr ss:
Telephone
ignature
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
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) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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` 16 HObLY CST BP-2002.0909
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV:Block:29 095 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-.0909
Project# JS-2002-1483
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot size(sa.ft.): 12980.88 Owner: SMITH PAUL L&THERESA D
Zoning:URA Aw cant. SMITH PAUL L & THERESA D
AP- 16 HOLLY CT
Applicant Address: Phone: Insurance;
16 HOLLY CT (413) 586-1784 O
FLORENCEMA01062 ISSUED ON:4122102 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL V1 NYL SI DI NG
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 Finals
Final: Final:
Rough Frame:
Gas: Fire Deoartment Fireplace/Chimney:
Rough: Oil• Insulation:
Final: Smoke: Final: Off Al- ;23-03
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of ccu anc Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/22/02 0:00:00 4572 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo