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22D-070 �tt1AMP�0 - 9 6 �asaschasctts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMTENSATION INSURANCE AF t AVIT I, (licenserJpermi��ee} with a principal place of business/residence at: (phone#) (street/city/s-taie/rip) do hereby certify, under the pains and penalties of pequry, 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 Corupar y/Policy Nurnbcr) (Fxpiradon Date) (Name of Contractor) (Insurance Company/PoLcy Number) (Expimdon Date) (Name of Contractor) (Laurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach addiboexi ahoet ifnxeusxy to include infoemstioa pertaining to ell eaaradvrs) ( ) I am a sole proprietor and have no one working for me. �I am a home owner performing all the work myself. NOTE:p1case be avare that while homcownaa who employ persom w do m*hjt'*•ncc�con3t7ictioa or repair work on a dwelling of not mote than throe units in which the honmoowncr r=dca oc on the grounds appurtenant tbereto arc not bey ooandcrcd to be employ=under the worker's c mpcus4oa Act(GL152,ss 1(5)),application by a homeowner for a hazier or permit may evidence the legal Bahia of an employer under tho Workee,Compensation AL I understand that a copy of this rEatcmcat may be fmvrmA-W t-the Depot of Iii d Acad-&Office of Lw=D-for the oovtma verification and that failure to&cane coverage under scetion 25A of MCIL 152 can lead to the imposition of criminal pcaaWcs coaustiag of a fine of up to 51,500.00 anNoe bnpr6om=z1 of tip to one year and civil p=,d ics in the form of a Stop WorkOrd-and a fum of S 100.00 a day tpinst me. For dgrrrtmc —oaty ` Permit Number Nfap4 Iot# �l Signatu�(,f ce nseejpermittee e SE`i 1 0 X44,5 0T,FtUpTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone �s:e r 1)rn mp auerfent-C7 ntiactor� � • „, ,� ,,,, Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTIQNi310 WORKERS',COMPENSATION INSURANCE=AFFIDAVIT(M.G.i. 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...... ❑ NEW- 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. ZHorneowner Signature SECTION. _.DLon '[:�, R' POS�O� `�c c aka licable s » 3 t „ New House ❑ Addition ❑ ReplacemenjeWindows Alteration(s) ❑ Roofing ❑ Or Doors 17 Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Cej(o'ce Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 6aIfNew` hous �a�nd o atltlition toetis"ting�.housing "compl°ete�the.fol.lowin�: 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 SECTION;7a�.OWNER'AUTHORIZATlON -,TO BE COMPLETED WHEN OWNERS AGENT OR CgNTRACT,OR APPLIES F,OR BUILDING 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. Signature of Owner 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 Signature of Owner/Agent Date r f ' 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 e phone 413-587.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION)-SITE INFORMATION This section to- 'e�completed.p"y�of c'e� 1.1 Property Address: w, O 5 Zone N �� Q�er a�D�strt t �Y �x1 � . z ? x W Elm St "District' SECTION`2- PROPERTY OWNERSHIP/AUTHORIZED,AGENT 2.1 Owner of Record: Ob Name(Print) Current Mailing Address: �� c�C` Signature Telephone cl 7 A 7 l 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. Building (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) °""' o® Check Number This Section For,Official,Use�bnl BuildingPermrt_Number Date Issued Signature Date• Bu�ldig,,Cornmrssioer/Jn�pectoro> Buttdliigs B P 2002 0464 GIs#: COMMONWEALTH OF MASSACHUSETTS :ll3ock: b-`0�0` CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: Windows replaced BUILDING PERMIT Permit# BP-2002-0464 Project# JS-2002-0702 Est. Cost: $2000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq. ft.): 15246.00 Owner: LAMPIASI MATT& LISA Zoning: URA Applicant. LAMPIASI MATT & LISA AT. 86 FLORENCE RD Applicant Address: Phone: Insurance: 271 BROOKSIDE CIR (413) 586-4421 (� FLORENCEMA01062 ISSUED ON.10/29/01 0:00:00 TO PERFORM THE FOLLOWING WORK.REPLACE PORCH SCREEN WINODWS /INSULATED 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: 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 10/29/010:00:00 731 $25.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Building Commissioner-Anthony Patillo q i r 86 FLORENCE RD BP-2002-0464 GI-$-= COMMONWEALTH OF MASSACHUSETTS MQ Block::22D-070 CITY OF NORTHAMPTON Lot:=001 Permit: Building Category:windows replaced BUILDINGPERMIT Permit# BP-20-02.0464 Project# JS-2002-0702 Est.Cost: $2000.00 Fee: 25.00 PERMISSION IS.HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot Size(sq ft): 15246-00 Owner: LAMPIA 1 MATT&LISA Zoxung URA AMlicant: LAMPIASI MATT& LISA An 86 FLORENCE RD AntpIuantAddress: Phone: Insurance: 271 B&OOKSIDE CIR (413) 586-4421 FLORENCEMA01062 ISSUED ON.101291010:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH SCREEN WINDDWS /INSULATED REPLACEMENT WINDOWS POST THIS CARD SO IT ISM LE FROM THE STREET Inspector of Plumbing Inspector of Wir€ng D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: F Driveway Final; Final: Final; Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation Final: Smoke: Final: OTC II-»g-©l THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA ON OF ANY OF ITS RULES AND REGULATIONS. -0 zwq - ..fit• ertific e f nG Si nature: Fee Tyne:; Recei»t No: Date Paid: Check No: Amount: Building 10/29/010:00:00 731 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo