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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building o�y
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
Ya
{licenserJpermittee)
with a principal place of business/residence at: /
.(phone (n l
(street city/statelap)
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 Daze)
�Q I am a sole proprietor, general contractor o homeowner cle one) and have hired
the contractors listed below who have the followingz won et's compensation policies:
an ct( .
(Name of Con error) (Insurance Company/Policy Nutnbcr) (Expiration Date)
C 4 K-I r\
(Name of Contra r) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attad,additional shoes ifneceuary to kW11.1 a information perbLining to Ull ooatr'aGl )
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pleaae be aware that while homcowuen who employ pusoas to do maiutrnance,cossstrvctioa or repair work on a dwelling of
not more than throe units is which the homeowner mid=or on the grounds appurtenant thereto are not generally ooandavd to be
employe m undcr the workcez compensdion.Act(GL152,ss t(5))�application by a homeowner fora license or permit may evidcace the
legal ctatrra of an employer under the Worms C,ompematioa Act.
I understand that a copy of this"=rent may be forwrvded to the Depart ncat of In&mtrial Aodden&Office of Imursnce for the
coverage verification and that failure to—=coverage under soctioa 25A of MOL 152 can lead to the=posit—of-mind Pcniddes
consisting of a fine of up to$1,500.00 andlor imprisonmeszt of up to one year and civil penalties in the form of a Stop Work order and a
fine o(3100.00 a day against m
gPermit me�use only
Number Let#
Si of i ermittce
^ °
8.1 Licensed Construction Superviso Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not App icable 0
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.
The current exemption for^houeonnem'`was extended to include one(1) or two(2)families
and uo allow such homeowner to engage uo individual for hire who does not possess ulicense, 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 buildine permit.
As acting Construction Superviso 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 ioDeath)of the Muao uubno��o G euc/u|Lmvo Annotated, fonponoo(o)
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.
Signature�t
SECTION 5- S OA a `c 1
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding( ] Other[ ]
rief Description of Proposed Work: t S �j 'K- y U.)0 ur
�t(fie
Alteration of existing bedroom Yes No Adding new bedroom Yes No t,
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
s
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: J 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? 09-1 b t�a-e )0044_ 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 RE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.6UII:DING PERMIT
I 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 wner 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 perjjr�ry.--
14 A
Pri ' /l
t 1" •� Vv
Signatur Owne /Agent Da e
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 y
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
Building Department
212 Main Street
_d_,4 oom 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
SECTION 1"-SITE INFORMATION
k � h ii t eo� �e� n'P
1.1 Property Address: N `
`f � ' " k`
s
My
SECTION 2-PROPERTY OWNERS HIPIAUT'HORIZED AGENT
2.1 Owner of Record:
a
Name(Print) Current aili Afd�d ss: .h5lt`
Telephone SLS�
igna re
2. uthorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SE TION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building s (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 = (I + 2 + 3 +4 + 5) Check Number r I --�
This Section Far Official Use Onl
Building Permit Number: 414 Date Issued:
Signature:
Building Cor6missionerflpspector of Buildings Date
5
File#BP-2001-0449
APPLICANT/CONTACT PERSON LAWTON JENNIFER GARRATT
ADDRESSIPHONE 1357 BURTS PIT RD (413)586-1761 Q
PROPERTY LOCATION 1357 BURTS PIT RD
MAP 35 PARCEL 170 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid e S
Typeof Construction: SHEETROCK,SIDING&REPLACEMENT WINDOWS/SIDING ON GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
TH OLLOWING 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 Conservatio mmission Permit from CB Architecture Committee
�- 2000
Signature of Building Official 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.
1357 BURTS PIT RD BP-2001-0449
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 35- 170 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0449
Project# JS-2001-0766
Est.Cost:$3500.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(q.ft.): 30056.40 Owner: LAWTON JENNIFER GARRATT
Zoning: SR Applicant: LAWTON JENNIFER GARRATT
AT. 1357 BURTS PIT RD
Applicant Address: Phone: Insurance:
1357 BURTS PIT RD (413) 586-1761 ()
FLORENCEMA01062 ISSUED ON.1113100 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK, SIDING & REPLACEMENT
WINDOWS/SIDING ON GARAGE
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/3/00 0:00:00 6135 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo