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Z, Jn T to � L KGB D F 7- - Lf, T m oL � a za -� La f T V� l �j 1 V b r 'r1 G t �- ,� _ � z -�" n Z �� � _ I h it -r! -1 o� 9 N r 1 v1 J �1 F- G' I v . "T! Y r G✓ .�j 09010 YW'NO1dWdN180N SNO1103dSNIWON JO 1d30 1002 9 - Nnp v� 4-�NMrP�.p � Grit 7 of Wart4aiiipt i V 9 $ �i36iC{�r8Ct11S DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVTr with a principal place of business/residence at: xt—) Y_ _ (phoneg) (street/city/statclrip) do hereby certify, under the pains and penalties of perjury, that: M1I am an employer providing the following worker's compensation coverage for my loyees working on this job: (LnsuranaetCompany) (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) (Expirntion Date) +r. (Frame of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Lnswan(-- Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach u"fioa l shoo ifnocc s to include information peztaiuing to all contractors) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plcaw be aware that wizilo homcow=3 who cmplay per;ons to do mainr,+,+nc,�comtr r oa or repair work on a dwelling of not more than throe units in which the bomeowncr resides oc on the grounds appurteaani thereto tiro oot gcncrally oowtdacd to be cmployaa under the w%*.cez mmp=u;iicn Act(GL152,ss 1(5)),application by a homeowner far a license cc permd may cvidcaoc the legal status of an employer undertho Workoes Compomation Act 1 understand that a copy of this sratcmeat may be forwnrdod to tbo Dcpartnocni of Indwfrid Aocidmt3 Ofhoc of La rte for the coverage vmficaiioa and that failure to wane oovc a under sccuoa 23A of MGL 152 can lead to the inzposdioa of criminal pcmltics ooasisting of a fine of up to S 1,500.00 andlor imprisouma it of up to one ytar and Ci I penalties in the form of a Stop W orlc Orda and a Em 0(5100.00 a day agairssi me. For depart=*'uao oaty Pe.r nit Number { Si of Licence ttce ECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ ame of License Holder: C fit`{k,(a�Q License Number idress Expiration Date gna rE Telephone EE Not Applicable ❑ Y@ n r tl ` C r a 3..aa>s .. . P P ompaanv Name Registration Number t 5-% & ddress Expiration Date Telephone ECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, §25C(6)) /orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit -ill result in the denial of the issuance of the building permit. igned Affidavit Attached Yes....... ❑ No...... ❑ M11"t~,�r��x�mbt�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" 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 ECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) 'ew House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ ccessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] rief Description of Proposed Work: r j teration of existing bedroom ✓ Yes No Adding new bedroom Yes �� No ttached Narrative D Renovating unfinished basement Yes No ians Attached Roll D- Sheet a: New:;ho. tea° tl r.' d i i n to a Is#r' hv`u!s�n `COrri"`le a{the:<fo lowin Use of building : One Family Two Family Other Number of rooms in each family unit: Number of Bathrooms_ Is there a garage attached? Proposed Square footage of new construction. Dimensions Number of stories? 1 Method of heating? LN, ( Fireplaces or Woodstoves Number of each Energy Conservation Compliance. Mascheck Energy Compliance form attached? Type of construction !s construction within 100 ft of wetlands? Yes L/ No. Is construction within 100 yr. floodplain Yes V No 1 �1 Depth of basement or cellar floor below finished grade�l, Will building conform to the Building and Zoning regulations? Yes No . Septic Tank City Sewer Private well City water Supply "ECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN )WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT' as Owner of the subject property ereby authorize to act on iy behalf, in all matters relative to work authorized by this building permit application. ignature of Owner Date .�„ as Owner/Authorized Agent lereby ecl that the stat ments a d information on the foregoing application are true and accurate, to the best of my nowledge and belief. >igned under the pains and penalties of perjury. tawn!ejr/A—gernt 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 , V Frontage Setbacks Front 3 Side L: R:�� L: rjO R: Rear ��t LA 7 d Building Height Bldg. Square Footage dQ� % L � Open Space Footage �cjj� ,� % \ (Lot area minus bldg&paved /( ,l/1'La Q� 1 10 parking) #of Parking Spaces �. Fill: F� volume&Location) v 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 v i of Northampton u ing Department _ 2 Main Street Xj ?�Ol a Room 100 ! rtha pton, MA 01060 SPE pE°7 OF BUILC � -587 1240 Fax 413.587.1272 NOR?HAM�� € APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ECTION 1 - SITE INFORMATION ��` �� This sectiatl be,con �et ��� pf�il .1 Property Address: lid 0 f . " a:- ,3,., b +f Zen SECTION 2 -"PROPERTY OWNERSHIP/AUTHORIZED AGENT" .1 Owner of Record: lame(Print) Current Mailing Address: Telephone ignature !.2 Authorized Agent: ` Ja e(Print) Current Mailing Address: � nat re Telephone iEGTION 3 - ESTIMATED CONSTRUCTION COSTS tem Estimated Cost(Dollars)to be Off iciaWse Only completed by ermit applicant 1. Building (a) Building Permit Fee ?. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 5. Total =0 + 2 + 3 +4+ 5) Ci Check„N6mber '7hif"Sect onl a'r.Official Use, nl Bull,I,ng:Per mit:Number. "" Date'Issued: �7 Si �tur�e BuEld►ng C ommA�sionerllrrspector of Buildings, , Date x i File#BP-2001-1014 APPLICANT/CONTACT PERSON CDT CONSTRUCTION ADDRESS/PHONE 158 NORTH MAPLE ST (413)585-8677 PROPERTY LOCVON'I' - SPIT RD THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid c �n Typeof Construction: CONSTRUCT 21 X 6 ADDITION TO ENLARGE BEDROOM/BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 003666 3 sets of Plans/Plot Plan THE FOLLOWING 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 , w/ZONING BOARD OF APPEALS �m ding Required under: §�..3 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 Comm' sion Permit from CB Architecture Committee � 110e 6 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.