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16A-020 (2) .citAMp 4p .2- y e ., - Q Lrt tf " L1rtI 1 & m ptan � _* k w .��/►� .. / d a saarEfnactta ' °`� _ ^�W ' � DEPARTMENT OF IIUILDING INSPECTIONS • _ i - 212 Main Street • Municipal Building _ Northampton, Mass. 01060 ''' -' " WORKER'S COMPENSATION INSURANCE; AI E'I)AVTT 1, (licensee/permittee) with a principal place of businessiresidence at: • (phone #) (street /ci ty /scat eJa p) do hereby certify, under the pains and penalties of perjury, that: ( ) 1 am an employer providing the following workers compensation coverage for my employees working on this job: - (Incar2nce Compan (Policy Number) (E-xpiration Date) X 1 am a sole proprietor, general contractor o homeowne . cle one) and have hired the contractors listed below who have the folio n • ' or er's compensation policies: ame of ontractor) /(Insuran. /Company/Policy Number) (Expiration Date) l q. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necessary to include information pertaining to all contractors) ( ) 1 am a sole proprietor and have no one w orking for me. ( ) I am a home owner performing all the work myself. • NOTE: ptrW bc aware that whiro homeowners who employ per om to do Dan i a re m . ruc-ioo or repair work on a dwelling of not more than three units in which the loonotowner resides or on the grounds appurtenant t ercto arc cot generally ooaridered to bc employers under the worker's compeasstion Act (GL152,ss 1(5)), applir,tion by a homcownor for a license or permit may evidence the legal status of an employer under the Worker's. Coaopemation Ad. I understand that a copy of this ctatcmeat may be forwarded to the Dep utn st. of Industrial Accidents' Oflioo of In5oranco for the coverage verification and that failure to secure coverago under scciion 25A of MOL 152 can lead to the imposition of criminal penalties oonsittiug of a fmc of up to S1,500.00 t mdlor imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a rim of S100.00 1 day against me. (. . For dcpsrtnndsl moo only Permit Number Map t Lot # i ., • • © Icensee/Permittce Oa e SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone PP Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 ❑ No ❑ OM WI " uwinem. ;EiFb �1g 6.1X`. 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, S and Local Zoni • _ a s and State of Massachusetts General Laws Annotated. Homeowner Signature _ it SECTION 5- ?DESC'RIPTION:.OF PROPOSED WORK;(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other'} Brief Description of Proposed Work: It,. v , Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet 0 6a. If Neuvw ho ' e andbo 4eddition'to existing - iousing,..completethe 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. 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 AUTHORIZATION - TO BE COMPLETED WHEN OWNERS.AGENT'ORCONTRACTOR APPLIES FOR 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 , 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 N. / Signa re . Ow /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: City of Northampton S'' •' r a __ Building Department �` S �� S , [ 212 Main Street S , i Room 100 er ; Northampton, MA 01060 T' ® etsr 1' ` � � 1 ? ^1 — ' ^hon� 4;'li -587-1240 Fax 413-587-1272 p d ISe� ``APPI,IC'A "0 CO STRUCT ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION Property Address: This section to ,be completed by offi o f / ( )A c l / 6 - Map Lot Unit //OAR • � -- Zon �� }, � e�erlayDistrict� f Elm St. District CB District SECTION 2 -- PROPERTY OWNERSHIP /AUTHORIZED AGENT �2.1Owner of Record: C)AIt - c ' sit Uc 3a t<Af v t4.;A(7 Name (• Current Mailis d Bess: )1AzSS- I I I I I I I I I W— .• Telephone Signat e 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated CostiDollars) to be Official Use Only completed by permit applicant ✓1. Building 4 &iC (a) Building Permit Fee 2qU (I U . �C rc 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 Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 302 FAIRWAY VILLAGE BP- 2002 -1065 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A - 020 CITY OF NORTHAMPTON Lot: -032 Permit: Building Category: BUILDING PERMIT Permit # BP- 20024065 Project # JS- 2002 -1711 Est. Cost: $2000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): Owner: LISSAUER JOAN Zoning: URA/WSP/WP Applicant: LISSAUER JOAN AT: 302 FAIRWAY VILLAGE Applicant Address: Phone: Insurance: 302 FAIRWAY VILLAGE (413) 587 - 0717 0 L E E D S M A01 Q6 ISSUED ON :6/4/02 0:00:00 TO PERFORM THE FOLLOWING WORK :INSTALL WOOD PELLET INSERT 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: G R 6-5•6'9, - 1L v • THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS / Certificate of Occupan Zitdl si. nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/4/02 0:00:00 547 547 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo