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23A-108 133 SOUTH MAIN ST BP-2019-0338 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.-Block:23A- 108 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2019-0338 Proiect# JS-2019-000548 Est. Cost: $1200.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Gronn: PAMELA LEBEAU 064756 Lot Size(sq. ft.): 14069.88 Owner: FITZGERALD JOHN E Zoning:URB(100)/ Applicant. PAMELA LEBEAU AT. 133 SOUTH MAIN ST Applicant Address: Phone: Insurance: 248 Bryant St (413) 296-4506 CHESTERFIELDMA01012 ISSUED ON:9/21/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACEMENT FRONT DOOR WITH 2 WINDOW INSERTS 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 9/21/2018 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -§lTE INFORMA'FtOC+f 1.1 Property Address: -�^.^:-max ;�� 1��`�•. T�" ��.�1' 45 iffil Wwni s -50 _ s �Wim. ..a.. 1aa•.,. - "rrt'1 t-,. i-`��,� SEC 614,i.PROPF.it 6Y`0WNERSHIPfXCk` 0i31�EEF�6_E 2.1 Owner of Record: - Name(Print) Current Halling Add s.. V Signature t Telephone 1 7 `l \11 Q� 2.2 Authorized Aoerit: Name rint) Current Mailing Address: p Signature Telephone 4 SECTION 3-ESTINIATEE>•'C0NST12UGTE0NjG0 Item - . Estimated Cost(Dollars)to be Official Use Only completed by permit app licant 1. Building (a)Building Permit Fee C�Zv v 2. Electrical (b}Estimated Totat.Cost of Construction f ni 6 3. Plumbing Building PermttFew 4. Mechanical(HVAC) q0 0 0 0 5. Fire Protection 6. Total=(1 +2+3+4+5) 1,,Check Number ThEi SealEfn^Foir-ORiciirtfte On Building Permit Number fssuee: Signature: r t.� 9 zo 1- 1 Building Commissanedinspeetor of B.ukw gs Deft �rr1 Q 44 e f zo C yl,-- 780 CMR STATE BOARD OF BUILDING REGULATIONS AND STANDARDS THE MASSACHUSETTS STATE BUILDING CODE SECTION 4-WORKERS'COMPENSATION INSURANCE AFFMAVrr CILGA.C. 182.9 Z5C(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....... eo� No...... ❑ SECTION 8-DESCRIPTION OF PROPOSED WORK(check aU applicable) New Construction ❑ Erdsting Building ❑ Repair(s) Aiteration(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify' Brief Description of Proposed Wo -Dao SECTION 6-ESTIMATED CONSTRIICTION;iwT Item Estimated Cast(Dollars)to be omelat.tbe only completed by permit applicant 1. Building (a)BWimog`FatmfiPee lltttltipoleer; x? 2. Electrical (b)Estlmated'1bhLCaslof :: a:.e „ e::. a• w.:; : ; 3. Plumbing , a 4. Mechanical(HVAC) lsiait aes ? S.Flm Protection : a..x... -•.�` >• 6. Total!w U♦2+3 4.S) Check Dhrmber SECTIOMU-'4OWREitADTSORITaTJOX ;'MJKMCOP0%ZZa OWN=AGMT.Olt CONTRACTOR APPIMS FOR BUXEMMG PERIIM L U n•1TZ©� as Owner of the subject property hereby authorize // M to act on my In all ma athoW!thw.bWti(ding permit application. SWarure browneK Dare 5EC1TOlr?d-afW�i��tftl/AD'iSoElOi�nD11"DM LaBAliOif L �A'M l%C�i T Cr�7 �T F 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. Slgn der the pains and penalties of perjury. t3 Priv Name signature of-Owner/Agent Date 672 780 CMR-Sixth Edition 217/97 (Effective 2/28/97) ' 1 SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: )) Not Applicable ❑ Name of License Holder:- tq 6� L 4�t" -fit- License Number 16 j3e_y mm 7Ad s � Expiration Date 6145 c99 e-zrs_& 57 y '712,51 Z©� Signature Telephone 9::Reilistered'Home Improvement Contralto Not Applicable ❑ Company Name Registration Number—-- / um er —-- / / / Zz)2v Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,.f25C(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...... ❑ Wt 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 1083.5.1. 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-vear 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 r � . .'i _« ... rt .4 .; .. .. t ... The Commonwealth of Massachusetts Department of IndustrialAccidents w Office of Investigations 1 Congress Street, Suite 100 r Boston, MA 02114-2017 i ',M 5•�' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information -� Please Print Legibly Nance (Business/Organization/Individual): (�/� 1��tRrr� Address: �Oq P) City/State/Zip: Phone#: C� V13 � Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.MI am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policy#or Self-ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: 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 ce ' under the pains and penalties of perjury that the information provided above is true and correct Si afore: I Date: Phone#: / —5-25-- S Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other