18C-096 (3) •
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'�"� :�' D EPARTMENT O F BUILDITIG INSPECTIONS 4
212 Main Street • Municipal Building _
Northampton, Mass. 01060 ��~ r'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
2--c-4 0 eA arCLcz___
(lipermittee)
with a principal place of business/residence at:
- ( 1 — ( 7 - 7 Li
t/ (i-. (? ,N (r `-z.._ (phone #)
(street/city /start i ip)
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:
- .t y t <.
(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 CompanyfPolicy Number) (Expiration Date)
If .
(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 at sary to include information pertaining to all coatreetors)
( ) I am a sole proprietor and have no one w orking for p.r am a home owner performing all the work myself.
NOTE: please be aware that while homcowncra who employ persons to do maintenance, construction or repair work on a dwelling of
not mote than throe units in which the homeowner resides or on the grounds appurtenant thereto arc not generally considered to be
employers under the waiter's coropcassiion Act (GL152,s3 1(5)), application by a homeowner for a license a permit may evidence the
legal statue of an employer under the Worker's Compensation Act.
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,300.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.013 a day against mc.
/ For departmental use oat) Permit Number
V 1 �; , �. ,,a f� Map4 Lot #
Si... .. • of Licensee/Permittee late
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
:t ° ` .:1 ):L.)iil. El 0 ta.4 it = : . 9 (1: ' e_" rkAt 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 ❑
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
/ N9 iampton Ordinances, State and Local Zoning Laws and S of Mass husetts General Laws Annotated.
v Homeowner Signature ()"" –67=02-12–
m , - - I • ► • • - OPOSEQ WORK (c epk all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Door'
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
' Description of Proposed Work: Pe — `' 4 • � Cti tsLIPQUJ (4) V &`LO LONI
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet 0
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS! AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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
VT1-4-111/21:) , 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 Na e
AN, / � - ��
Signature of Owner 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 V DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commi ion?
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:
Y =
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City of N. ! pton
MAY )1u g l► tment , a" ��
M. Ireet
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DEPT Of BUI
NORTHA . � � � . � {,; `, n, M , 01060 4 <�� � , � ������..� r� � �'
Z. ,�i'. , . - x 413-587-1272 ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION g
<, i4-ee'WttlOn ® @ W 3 te' 1 R :,� f t ( t
1.1 Property Addre ��J� .4, ;ef "4 � , s ,
Elm. St. D st lc __ i CiE 'j , ,,
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: I
re Ci,k N‘■e.-D (Piki/A-C---(,---E-E - ...-- , i \ it...4__ C .
Name (Prii / Current Mailing _ i , `
_ ,. i.3 411.411. Telephone J�! y
Signature
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 permit applicant
1. Building L- 'J(r C \t-r O O (a) Building Permit Fee
2. Electrical 1 /'� (b) Est Total Cost of
` J T Construction from (6)
3. Plumbing 1-\1-11 A Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection Q/11
6. Total = (1 + 2 + 3 + 4 + 5) L� S - 1-fes K $ t7 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
'Building Commissioner /inspector of Buildings Date
4014B - BP- 2001 -0934
GIS #: COMMONWEALTH OF MASSACHUSETTS
°: • . : ° - g CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit # BP-2001 -0934
Project # JS- 2001 -1683
Est. Cost: $500.00_
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 1 001 8.80 Owner: LAVALLEE RICHARD
Zoning: URB Applicant: LAVALLEE RICHARD
AT: 4 GLEASON RD
Applicant Address: Phone: Insurance:
4 GLEASON RD (413) 584 -1774 ()
NORTHAMPTONMA01 060 ISSUED ON :5 /17/01 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL PORCH REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
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 5/17/01 0:00:00 329 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo