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35-227 (2) � : �ausclituctti i DEPARTMENT OF $UILDDyC INSPECTIONS 212*Main Street ' MunicipA•Building Northampton, Mat s. 01060 WORI'CER'S COMPENSATION INSURANCE AFMA.VIT with a principal place of business/residence at: (phone#) (str�tki tylstair./zi p) do hereby certify, under the pains and penalties of perjury, chat: am an employer providing the following workers compensation coverage for my employers working oa this job: (Lasu?ana Company) (PoliryNumbcr) (Exp fn do dD iu) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insuran=Compauy/Policy Number) (Fxpirmtion Datc) (Name of Contractor) (Iruluantx Company/Policy Number) (Expiration Datc) (Name of Contractor) (Insurance Company/PoGcy Number) (Expiration Dace) (Name of Contractor) (Lnsurmm Compzay/Policy Number) (Expiration Datc) (ana.ea s6&60ml sboee ifnooenary to 6dudc iafocmatioe pert:izang to all 000.7eGOn) ( ) I arri a sole proprietor and have no one working forme. ( ) X am a home owner performing all the work myself. NOTE plcsae be aware that t+hiJo bomcowom wyo c�p(oy persocss to da a. + ooc sctioo or rcpa c work oo►dwCTMz of J m4 mocv than tbroo ugiu is which the bomoownct resides of oa the tieuads Tpwut tbcMo ate Dot Caw.11y ooazidacd to be employen uodcr tba wocktex pompea&4oa Ad ap Umsou by a homeowm fee a u—cc pm-aid may cvideme the legal staaua*r&Q employe ued.t the W"kaes Compemaiioa Act• I uaderN ad that a copy otthia t>stemmd may be tai+r+rd.d to the Dep.stmc of otIoda+aAi.l A�idomtf t�iw of Isvunnw fa the oo+^azgevcri$catioa taad that filuce to t:ocure oovcc>,to ta�det soctioa 2SAoCMOL 132 oa!ad W tbd imposiSoa eCetimind,pca►1$a 00osts6=g otst fie urup to s 1'500.00-&-impr60=XrA oCup to ooe yru Sad civil pernriia;a the form oCa stop Work or&r and a :1 fimQ(SL00.00&day rp!=Aw= . FocdcpatEmoobttsaeeoty permit Numbc r )&p; Lot i sic taf Li _ ' . crew SECTION 8-CONSTRUCTION SERVICES Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder J 63 I e j45 License Number ,dam Address _ ' Expirati n Da Signature Telephone SAVE M- Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION_IN SURANCEAFFlDAVIT(M,G,L G. 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...... ❑ x .: gym., € 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 buildinE 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 —CTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ / Brief Description of Proposed Work: -5 ��' 9,r' 17 "�> g4/27 0y r J �'`1 05 Alteration of existing bedroom Yes No Ad//ding new be droom Yes No Attached Narrative J Renovating unfinished basement Yes No Plans Attached Roll Sheet sa. If New house and'or addition"to existing housing. complete the following:. 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? 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 hereby authorize to act on my be in all ma ters relative to work authorized by this bui ding permit application. 11 Signature of Own r Date as Own�A�orized Agen hereby declare that the statements and in ormation on th foregoing application are true and accurate, b-fMi_'-n o my knowledge and belief. Signed under the pains and penalties of perjury. Print Name _ Signature of Owner gent Date Ala' rthampton t . BI.W digit epartment 2 3 12' Mafn Street o rri� 100 orthampton, MA 01060 phone 41-3=587-1240 Fax 413.587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: �Thrs sectiii to b ;rompletedby;affice' Lyot Unit zone iJverEaj(District "Elm CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na e Print Current Mailing Add r ss:� 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 1. Ctr' (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 This Section For Official Use Only Building Permit Number:' Date Issued: Signature:. Building Commissioner/inspector of Buildings Date r 58 LADYSLIPPER LANE BP-2000-1053 CIS#: COMMONWEALTH OF MASSACHUSETTS Map-Block.-35-227 CITY OF NORTHAMPTON Lot:-001 Permit: Buildinq Category:roofing BUILDING PERMIT Permit# BP-2000-1053 Project# JS-2000-1892 Est.Cost:$5400.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Alan Shumway 103721 Lot Size(sq.8.): 32452.20 Owner: ZASHIN LYNN S&AMY P JACOBSON Zoning: SR Applicant: Alan•Shumwav AT. 58 LADYSLIPPER LANE Applicant Address: Phone: Insurance: 625 EAST PLEASANT ST (413) 549-9658 Workers Compensation AMHERSTMA01002 ISSUED ON:5123100 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 No: Amount: Building 5/23/00 0:00:00 2369 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo