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.�yy D EPARTMENT OP BUILDING INSPECTIONS = � -i _
• 212 Main Street • 'Municipal Building
-4
Northampton, Mass. 01060 ," �'��
WO • • l 'S COMPENSATION INSURANCE AFFIDAVIT
I, /.
(ii pemaittee)
with a principal place of business/residence at:
2 S li/v\ ,Ve (phone #) -e -33S
(street/city /state/zip)
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:
ri' }
4 (Insurance Company) (Policy Number) (Expiration Date)
( ) 1 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)
1 1 .
(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 Meet if necessary to include infornuton pertaining to all contractors)
a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do mamfrn +n e., construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto are not generally coasidercd to be
employers under the worker's compensation Act (GL15243 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Waimea Compensation Act_
I understand that a copy of thu statement may be forwarded to the Department of Industrial Ac iden t:I' Office of Imo/wca for the
coverage verification and that failure to secure coverage under section 25A of M(OL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to 51,500.00 andfor imprisonment of up to one year and civil penalties in the form of a Stop Woric Older and a
fine of S 100 a day against ma
For dga¢1rae�al tun city
A_____----- Pmt Numb
m_ - Lot # •
Signature of Licenseefpermittee Date
ig
pTIQN 8 • CONSTRUCTION SERVICES
1 Licensed Construction Sup vi or: /" Not Applicable
Name of License Holder : cnc �. C ( r i A h
License Number
Z /07/02_
Address it/ / Expiration Date
-- 33Ce
Signature Telephone
' Not Applicable ❑
Company Name Registration Number Giv7b2
Address Expiration Da
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.
igned Affidavit Attached Yes -f' No ❑
A '
I Ili
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
.s .� PAOP. r WO; h- I a..1 able
New House ❑ Addition ❑ Replaceme t ndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: • / r ►k _
Alteration of existing bedroom Yes .-No Adding new bedroom Yes �No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
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?
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 A ITHORIZATION - TO BE COMPLETED WREN
OWNERS AGENT OR''CONTRACTOR APPLIES OR BUILDING PERMIT
464 _ , 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 - foregoing application are true and accurate, to the best of my
knowledge and belief.
igned under the pains . py / al of perj
Print Name /7J { p in
Signature of Owner /Agent Date
Section 4.
ern** ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DE D 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
erib 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 a any proposed changes to or additions of signs intended for the property ?YES _.
IF YES, describe size, type and location:
•
City of Northampto � ' v�
l i$118.4 Building Department �� k
212 Main Street`s
Room 100 as
Northampton, MA 01060 �� y�� ,, I
p hone 413 =587 1240 Fax 413 587 1272
Y `C ?9 3r' ¢
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW FAMILY DWELLING 11
SECTION 1 -SITE INFQRM ATION , p ,��yry� � et 1 1
k
■ ■ i i s section,,,, e A �fllI� ae..i 3 i s 4
1.1 Property Address:
' / � xy NORTHAMPTON 1 :;� 1s ie �< stria �s�r - : xb
E St District
SEI TION 2. Pitt PER'i 1( OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
C 4t1/4-1D
- (---g-a-ij--; .)4\1 en1V e 'rint) i Current Ma' d dress:
i
14 1. ' a / Telephone d
Signat -
2.2 Autho • ed A en
NI vf,e)Leto Or\
Name (Print) Cur rent Ma A ddress: /6 1 - 33 2
Signature Telephone 1,(/(1.._.
S TION 3 - S5TI ATI"D CQNSTI�U COSTS
Item Estimate Cost (Dollars) t o be Off Use Only
completed by permit applicant
1. Building t c'-‘° C-C) (a) Building Per mit Fee
2. Electrical (b) estimated Total Cost o f
C from (6)
3. Plumbing — Building Perm Fee
4. Mec hanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + -4.4+ 5 ) / �• Check Number
T his S ection For Off Use Only
Bui lding , Perm Numb Date Issued:
1 Signature.
Building C /Inspec of Bu Date
32 GLEASON RD BP- 2001 -0784
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 092 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit # BP- 2001 -0784
Project# JS- 2001 -1468
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Paul McCutcheon 100218
Lot - Size(sgft.): -1- 1238.48 ___ _ -- Owner : --- NEWKIRK MARTI
zo_URB Applicant: Paul McCutcheon
— —
AT: 32 GLEASON RD
Applicant Address; Phone: Insurance:
87 Chestnut St (413) 584 -3352
FLORENCEMA01062 ISSUED ON :4/6/01 0:00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL 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: 0 K '/' /3'0 l
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI , N OF
ANY OF ITS RULES AND REGULATIONS. .�
n .,
Certificate of Occupancy - pr Si. nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/6/01 0:00:00 4861 $25.00
212 Main Street, Phone (413) 587 -1240, Fax (413) 587 -1272
Building Commissioner - Anthony Patillo
•