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11A-034 f The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington,Street Boston,MA 02111 www.massgovtdia _ Workers' Compensation insurance Affidavit: Bulders/Contractors/Electri a Print m ers Aplalican�anon Name( pr on&&viduaT): Address• lv /�A1 % AA A N,57 - City/Staft/Zip: A . or3oi Phone Area an employer?Check the appropriate boa: Type of project(required): am a employer with _ 4. ❑ I am a general contractor and I 6. ❑New cou slrucdOu employees(b l and/or part tile).'° have hired the suit-contractors 7. Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ❑ ship and have employees These sub-arntractors have 8. ❑Demolition working for me is any capacity- workers'cep.insurance. 9. ❑ ,g adtlitien [No workers'comp.insurance 5. ❑ We area corporation and its 10.0 Electrical repairs or additions requa'�-] officers have exercised Heir 3.El I am a homeowner doing all work right of exemption per MtJL 1 I.❑Plumbing repairs Or additians myself.(No workers' coup. c-152,§1(4),and we-baveno 12.®Roofrepairs ice required.]t employees. [No workers' 13.❑ Other comp.insurance required.] 'Anye�ppliamt checks too#1 meat also fli calhe salon below showing their wo te&conpcnsadm policyinfbtmeticm: t Homeowaets who aabo tWs afdavit indicating theyare doing aII work aad their hire c td& ►actorsmust sutu�t a stew at'&davit g such =Camtraca that check this boa must attached sir additional sbeet slowing&e nsate offe and their workae cony.policy i 0mma 3oa. I an an employer that isproviding workers'compensation baursncefor my employees. Below is tie policy and job site hiformeam Insurance Company Name:_„77 Policy#or Self-ins.Lic.#:. �o t' !Q— 0,012.8 ,57-6— 07 Expiratian Date: S—O Job Site Address: 3 S E/} S-L C L ly J M S1 City/S : eeag Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify p,and penalties ofperJury_h1w the information provided above Is One and correct Sizutare Date: 0 T Phone#• 4/3 77 d 802 Qffleld use oralµ Do not wrfte in this urea,to be completed by city or Iowa offxW City or Tows• PernflMcense#. Co. 0^ex- - � w SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: i �/�(� ./ Not Applicable ❑ Name of License Holder: / , UP -e License Number OAY1AAID sr GP C"FiCLO M625 0 33s4 Address Expiration JDate Signature Telephone 9.Registered Home Improvemerit Contractor. Not Applicable ❑ ri M v PAZ e� Company Name Registration Number Lot., G" It L ADD 10 412-0 Address Expiration Date Telephone 7h ;A //o 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. Signed Affidavit Attached Yes....... Rk No...... ❑ IL - Home Owner Egempti©n 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 fi•om 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 � 1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors � Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding[0] Other[p] 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 6a.If New house and or addition to existing housing cornntete'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. Masscheck 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 BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 20A/VV D W!Zca property , as Owner of the subject hereby authorizes nR ey to act on my behalf, in all matters—relative to rk authorized by this building permit application. Signature of Owner Date 1, TI/h �, Pf2 c as Owner/Authorized Agent hereby declare that the tatements 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 —� 9 L06 Sign-sure of Owner/Agen Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 0 DONT KNOW 0 YES 0 IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued:" C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �Depar�mentuse�o�f� City of Northampton Stamm' P'ei-init . E s Building Department CuttGdtiDnrzeurr ;f3elrrttt x { 1'` 212 Main Street Sev�erisep c vaifabtfity Room 100 WaterMtell Auaifabiiit $ Northampton, MA 01060 Twits ofStruchzratPfarts fir? 1 p ne 413-587-1240 Fax 413-587-1272 Pfoffsife t=fans OtfierSpecify APPLICATION TO tONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section•to be completed by office 337 Eli ST C,eA Tcq SJ Map Lot Unit L-e t OS /n $3 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPLAUTHORIZED AGENT 2.1 Owner of Record: .TolyvAl DwXo 3�' C� S5 CC"V,TVi 31' Name(Print) Current Mailing Address: �/ yy LGEpS� MA Telephone Signatur(V (p 2.2 Authorized Agent: JIM pvPae/ 66 OAKLAND S j- GRCCA-r cL_D /7) Name(Print) Current Mailing Address: 0 13 cl 774- 210Y Signature e—� Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building Z%% —, (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=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date r BP-2009-0273 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category-i- BUILDING PERMIT Permit# BP-2009-0273 Project# JS-2009-000362 Est. Cost: $2880.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: TIMOTHY P DUPREY 104220 Lot Size(sq.ft.): 43560.00 Owner: DWYER JOANNE K Zoning:URA Applicant: TIMOTHY P DUPREY AT. 35 EAST CENTER ST Applicant Address: Phone: Insurance: 66 OAKLAND ST (413) 774-2809 WC GREENFIELDMA01301 ISSUED ON:911112008 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: 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: FeeType• Date Paid: Amount: Building 9/11/2008 0:00:00 $35.004546 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo