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35-185 (8) jNAMpTOy �x 7 laf 'Wart 4allip toil mm _ t � yna3a R[IlaBeltE DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, vY.aA r+ (licenser/permittee} with a principal place of business/residence at: ��'AAA� P)OMA ��1 01�(phone#)--`� 13� (streeVcity/swdZip) 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 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) (attach additiocal short ifnecenary to include information pa&=ng to all ooarecton) ( ) I am a sole proprietor and have no one working for me. (,�'Y am a home owner performing all the work myself. NOTE-please be aware that whilo homeowners who employ p==to do m&mj==c, mastr i on or repair work on a dvmlLing of not more than throe units in which the homeowner resides or oa the grounds appurtenant the rty are not scoCaffy ooasidtr d to be employ=under the worker's comp=s4ca Act(GLI52-a 1(5)�application by a homeowner for a license or permit may evidcam the legal ctatua of an employer under the Wockeet Compematioa Act_ I understand that a copy of this statement may be forwarded to the Dtputam2 of rnduafrial Ac6doa&Offioc of Insurance for the coverage vesificafion and that Wure to seatre covetngo tinder section 25A of MGL 152 can lead to the imposition of criminal penalties oomisting of a$ae Hof up to$1,500.00 andfoc ink of up to one year and civil penalties in the form of a Stop Work order sad a fim of 5100.00 a day against me. For dql use only Permit Number Map# Lot# L Si of Licensee/Permittee Date Wit �. _� �; � t - a 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone ' v : NotApplicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS'"COMPENSATION INSURANCE AFFII)AV1T:(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...... ❑ 1 , 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. r - Homeowner Signature 3 0 P S ©iNO hcab e , ,N...T'�'y�,..,,i�3.5C f,$,.n3' ' r✓'�.�i,.3.�.��� [ New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: ( )0,v0 t2z w�rv� Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 0 t °i' % i ,. R0 ft .rte 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 SECTQN 7'a 'OWNER A�THOIXA'TION -'TO OE COMPLETED WHEN OwNE S� 1 r vit ON7�2d►CTt) ;APP IES FO t UI�.b.M IG 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. 5- i Signature of 0 ner Date I, 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 II Signature of Owner/Agent Date i 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 ti� t- Setbacks Front Side L: R: L: R: Rear /u/4 / 4 Building Height X Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved �1 parking) #of Parking Spaces Fill: l� J A— 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: Yf" 1 a`S va ity of Northampton Building Department 212 Main Street MAY "" 3 20, Room 100 No thampton, MA 01060 _. " lUII..DINGINSOf WIt 413 587.1240 Fax 413.587.1272 `K MA 01060 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1-SITE INFORMATION This sects n to b- e',domple ffid y 1.1 Property Address: I�!lap Lot t UG t F Yi rto �GL(Ilil� n lo z verla i Dis r c� J • )Elm StY�sisi trtct ` N�?C�D� s ° ....v � , '` .; �� SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current iling Address: F-.af ev�LP 14U. c-'ki-A�n Telephone //o � �r Signatur c � I 4 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTIOWCOSTS' Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 00 2. Electrical LM (b) Estimated Total Cost of Construction from 6 3. Plumbing i DO Lo, LxZj Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4+ 5) 0oo • 0o Check Number This Sec#�a`rli°:Far Official' Use Onl Building Perrriit,t4umber: 6 Date Issued: Signature: ✓ `�` Building Commissioner/Inspector of Buildings Date . r .a4 BP-2001-0888 GIs#: COMMONWEALTH OF MASSACHUSETTS _ r .�- CITY OF NORTHAMPTON Lot: -001 Permit: Building Catecorv: BUILDING PERMIT Permit# BP-2001-0888 Project# JS-2001-1618 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R4 Lot Size(sq. ft.): 134600.40 Owner: CHILDS RONALD L&CYNTHIA M Zoning: SR Applicant: CHILDS RONALD L & CYNTHIA M AT: 34 PINE VALLEY RD AP licantAddress: Phone: Insurance: 34 PINE VALLEY RD FLORENCEMA01062 ISSUED ON.5191010:0 0:0 0 TO PERFORM THE FOLLOWING WORK.-DEMO AND MOVE BATHROOM TO ANOTHER ROOM IN HOUSE 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 Signature: Fee Type: Receipt No: Date Paid: Check o: k ount: Building 5/9/010:00:00 0845 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo Of Z%"'i� JOB WIN, - a "...-+..; I t Cr' t .9 w An t � v 3 { now OHIO z r 34 PINE VALLEY RD BP-2001-0888 GIS#: COMMONWEALTH OF MASSACHUSETTS Mag lock 35- 185 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2001-0888 Project# JS-2001-1618 Est.Cost: $3000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: R4 Lot Size(sq.ft.): 134600.40 Owner: CHILDS RONALD L&CYNTHIA M Zoning_SR Applicant. CHILDS k0ivNL'� L : CYNTHIA iVI AT.• 34 PINE VALLEY RD Applicant Address: Phone: Insurance: 34 PINE VALLEY RD FLORENCEMA01062 ISSUED ON:5191010:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO AND MOVE BATHROOM TO ANOTHER ROOM IN HOUSE 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:���� �C House# Foundation: Final: Final: a / ' �a Frame:h Rou g o� Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: &4#' i5%2&T.D 1 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc * Si nature: Fee Type: Receipt No: Date Paid: Check o: ount: Building 5/9/010:00:00 0845 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillr.