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32A-247 (2) 7 , � 4 Oi +r ii S./ U3 �� �.ptQl;�., 010-50 'wrnTO R E Clxf Of ��cr� f11alltpfoil _ g~ E �taraxchnsrtta — - o DEPARTMENT OP BUILDr)\'G INSPECTIoNS — 212 Main Street ' Municipal Building Northampton, Mass. 010GO WOMC?R'S CONII'ENSATION LNSURANCE AI FMANTIT Z�-- -- - - ---- -- - - - - - -- (li c.^nscr/pera�flee} with a principal place of business/re-sidenc.e at: do hereby certify, under the paint and penalties of perjury, :hat ( ) I am an employer providing the following Nvoriters compensZtion cove age for my elnployces wor�arlg on this job: (L sz�r�c-- Corr may) (PcL c:NLL-,abcr) --- (T=`pirtion Daze) ( ) I am a sole proprietor, general contractor or homeowner (ci_rcle one) and ,lave hired the contractors listed below who have the follo%IYUg worker's comoensa-6on policies: (Name of Con! c-,or) (lnsurancc Corrnaan}vPoi c-,Numbcr) (r>:�irdtion Date) (Name of Contractor) (Insaranee. Comoans•iPo'lq,Numt-zr) (ExpL .non Date) (Name of Contractor) (Imnuance ComT=y/PoUcy Numb,-r) (expiration Date) (Name of Contractor) G-GaIIauct— Comczuy/Policy Numbcr) (I �pisation Date) (&rich additioml sbctt ifnoccau to mdud �nfo,=uZ o pertn' wall 0007nco 3) ( ) I am a sole proprietor and have no one worlang for me. ( ) I am a home owner performing ali the work thyself. NOTE:plGSc be aw—that wt6Jo homcowt=73 who cmpaoy pcsom to do rr+mtl-+.= coa3=t:cioo ca-rgair work oo a d-niiing of not meet than thrno twits is wbxh the bomnowncr rmdes oc oo the grounds rtrpurt ia=tb,= o are oot gcoax oo=dc od to be cmploycr3 under the wo`s -tics Art(GI152-M 1(5)} appticuioo by a bomeoava far a Guasc cc permit may cvidmoc the Icgal ctaau of an employer under tfsv WOrkee,Compeoaatiou AcL I uxxicrmand that a copy of thin 03'e may bo focwerdnd to the Dcpartma i of Induz:n j Aoadcaa&(DM—of lmru+000 for tba oovcr'sc vcrificstioc and that L•iltac to scout:covcrnsc under soMoa 23A of h(GL 152 can Icad to tba imposiiioa of criminal penalties ooasistmg of a fine Of UP to S I X00.00 and/or of up to one year end civil pmattio io the form of a Stop wort Oder and a fim of S 100.00 a day agtiwt Mc For dcputmoc: 1 uac oaly Permit Number Lot" Sign of Liccnscc/Pc flee -fie SiCTION';I#„C44STRUgMN,SEIIVICES; .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone riC ,, r .�^ Not Applicable ❑ Company Name Registration Number ya Address Telephone � Expiration Date tom ,- 3 �s �°2 SECTIOht ltl WORKERS'COIVfPENS%TION3IISLIRANCE�KEFIDAVIT(M G.L c'152,§ fi} 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....... 99--- 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 tune,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 an ocal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature "�Cf f©i! 5 DESORfPi'1[7N QF I�R©RCSEa WORIGfcfteck alt ap�ficabfe) 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❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 SEC1`CQN ,QWNEI3'AUTHtJRIZk1(ON 7'D gE COfVfPLETED WHEN t OWNf=)tS AGEN" CE3N' ACTORPPf.IE �(} BI�II.DlIG;ftiEf2MIT as Owner of the subject property hereby authoriz A �QU to act on my be in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare thalAhe state nts 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. .A� Y Y A 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: hampton Buildi artment 9 dpi 2 n Street SEP R m 00 N on, A 01060 x 413-587-1272 NORZNpMP�Cx , APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT�01 StTE 1NFORMAT(ON 1.1 Property Address: 'Wo K T /mil Am SECTt€3N;2 PRUPEEtTY OWNERS.HIP/AUT" CC1R[ZED AGEt+T , 2.1 Owner of Record: 'S'TAWLC I!V1A- Name(Print Current Mailing Address: F�60�ii G Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SEC'I'I�N"�33...ES�fMATE -CONSTRUCTy01�rC�5'CS Item Estimated Cost(Dollars)to be ;official Use Oniy completed by ermit applicant 1. Building (a)Buildaing Permit Fee . 3, 3 Con 2. Electrical (b)"Estim"ated Total'Cos#of ibristructinn;from 6 3. Plumbing Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2+ 3+4+ 5) Cher"k Niarnber T his;Sec#iort'For,O cral„Use:OitN Bu[teitng Farm�trnber;. Da"te Issuecl� igga" !.al3u�ltiirtg Camrrrssivfirer"Ilnspectoi"af 6ui1"dings Date'- File#BP-2004-0274 APPLICANT/CONTACT PERSON Larry Paquette ADDRESS/PHONE 40 East Green Street (413)527-6375 PROPERTY LC3��.TI0I1. 9 FAIR$ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: NEW SIDEWALKS STEPS REDO PORCH FLOOR AND CEILING New Construction Non Structural interior renovations Addition to Existing_ _ Accessory Structure Cam— S� Building Plans Included• - Owner/Statement or License 100679 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P ELATED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Seppc Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Co ssion Signature of Building Official Da e 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. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information.