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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S CO'MTENSATION INSURANCE AFFIDAVIT
(licenserJpermittec}
with a principal place of businesslresidence at:
—_ _ _- --(phone#) __
(str��..2lcity/state/ap)
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:
(lamiranCC 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)
t.
(Name of Contractor) (Insurance, Company/Policy Number) (Expiration Date)
(Name of Contractor) (Lnatran� Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insumuce Company/Policy Number) (Expiration Date)
(attach additioml short if mccasary to if c 6'infocmafioa pertaiuing to all co'ft ors)
( ) am a sole proprietor and have no one working for me.
( I am a home owner performing all the work myself.
NOTE:plea=be aware that vA to hoaxowvcrs who employ pons to do rrza�croastuctioa or repair work on a dwelling of
not morn than thtr"o units in which the homooavcr residcs or ou the pounds appurtenant thucto ate not gcoavily oomidcrcd to be
employers under tha Wcrrkc-r's.o=gcas&ioa Act(GL152"1(5)�application by a homcowna for a 6ccux a permit may widener the
1eg21 status of an employer under the Woc S t Cocvpmlatiou Act.
I understand that a copy of this rbd=ent may be forwarded to tho Dcpwt=nd of Induutrid Ac6 a&Ofhoc of 1—u-&O"for the
coverage vcrificeioa and that U=to stc=covcaago anti r section 25A of MOIL 152 can icad to tha impo oa of criminal penalties
eomisIIug of a fine'of up to S 1,500.00 and/or hmprisoancnt of up to one year and civil pent is in the form of a stop Work Ocdcz and a
find of s 100.00 1 day tzgninst me.
For dq=-tal�ll1e oah'
permit Number
Map-4 Lot#
Signature of Liccnsee/Perm"ittee e
SECTION 8 ,CONST' U_CTIO.N SERVICES "
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
fle. « • . �
g- , �lmovmnCo o � Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 1N0RKERS';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....... ❑ 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 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 �(,(^
SECTIONS _D�ESCP III .'PR POSED''11YO.F2 .c eck all a licable
Ys ifuVSsTWb P'4i2A
», z ll "-, .; XS--AV„
,.,
New House ❑ Addition ❑ Replacemeryt Windows Alteration(s) Roofing ❑
Or Doors 10
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: )()J COO # PDkkA acl �,� d ao - ( n LJYq fl'► oul
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative V Renovating unfinished basement Ye
Plans Attached Roll 0 - Sheety
— "a ` d r f w- ea- otdUiti6t o ersn h6UsMng,ft mpleteAh' followrn :
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?
In. 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 OWNERAUTHQt(ZATION TO BE COMP..LETED WHEN
OWNERS ACENT�OR�C0NTRACTOR APPLIES FOR=BUILDING PERMIT
max. ,.....,
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.
Signature of Owner Date
f �f�{t6itJ �444teot%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
Signature of Owner/Agent Date /q C3
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/Fi7di 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 #
rook body B. Does the site contain a b y 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 V
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:
�CitV of Northampton
�' 2002 ing Department
21 Main Street
oom 100
pton, MA 01060 e
phone 413-587-1240 Fax 413-587-1272 P E,
�- Other' .
i
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION?1 - SITE INFORMATION
i 1.1 Property Address:
This section to be completed byKoffice�
. �� +�4
MapL�ot� =a
y_l Zone O�ertay Drstrrct
Elm St.°`District CB Dtiistrict
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
KA
Name(Print) Current Mailing Address:
Telephone C./� � /
Signature 6� � �-1 °f
2.2 Authorized Agent:
Name(Print) Current Mailing Address
Signature Telephone
SECTIONI3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
/019o. 00
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) 1000 o6 Check Number _
This Section For Official Use Only
Building'Pgrrn•rt Number: Date Issued:
Ar
Signature ,;
Bui,ldmg Commrss,{over.%inspector ofiBia,�.I,dInBS. Date,
File#BP-2002-0916
APPLICANT/CONTACT PERSON LAMPIASI MATT&LISA
ADDRESS/PHONE 271 BROOKSIDE CIR (413)586-4421 Q
PROPERTY LOCATION 86 FLORENCE RD
MAP 22D PARCEL 070 001 ZONE URA
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: ENCLOSE 9 X 5 PORCH ADD WINDOWS/DOOR&INSTALL REPLACEMENT
WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
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
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co ion
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
86 FLORENCE RD BP-2002-0916
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-070 CITY OF NORTHAMPTON
Lot: -001
Permit: B u i Ubg
Catego BUILDING PERMIT
Permit 4 E' -2002-0916
Project# JS-2002-1491
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(ss .ft.): 15246.00 Owner: LAMPIASI MATT&LISA
Zoning: URA Applicant: LAMPIASI MATT & LISA
AT: SO FLOI?ENCE RC
Applicant Address: Phone: Insurance:
271 BROOKSIDE CIR (413) 586-4421 ()
FLORENCEMA01062 ISSUED ON:4125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE 9 X 5 PORCH, ADD
WINDOWS/DOOR & INSTALL REPLACEMENT WINDOWS
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: inss.aCan:
Final: Smoke: Final: -0
THIS PERMIT MAY BE REVOKED BY THE CITY O ORTHAMPTON UPON VIOLAT N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:-�
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/25/02 0:00:00 791 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo