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�'W ' DEPARTMENT OP BUILDITIG INSPECTIONS C
' 'J 212 Main Street ' Municipal Building
Northampton, Mass. • 01060 � r'' � ``
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
Ocensc/pennittee)
with a principal place of business/residence at:
- (phone#)
(strtt / city /stair 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:
(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 Company/Policy Number) (Expiration Date)
(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 shod ifnocessary to include information pertaining to all contractors)
( ) I am 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 Vail* homeowners wt o employ person to do m+ n oonsructioo•ar repair work oo a dwelling of
not more than throe traits in which the bomeowow resides or oa the grounds appurtenant thereto are not generally 000side td to be
employes under the worker's compensation Act (GL152ts l (3)), application by • homeowner fora manse or punks may cvideoce the
. legal stasis of as employer under the Worlcds Compomatioa Act.
I understand that a copy atilt assttmeat may be forwarded to the Department of lndustrial Aeddmrf Ofoe of Insuraooe for t
*wane ve ificatioo and that failure to stare coveago under zoction 2SA of MOL 152 can lad to the' imposition of criminal penalties
cooriatina of a•fine of up to S1 and/or impcao®ed of tip to one yew and civil penalties in theform of Slop Wade Order and a
•
Sae of 3100.00 a day against toe. .
• - • . - For dcpartaosdalrisaonly -
i':. ... . 4.4"..„ ,n ,'L . • I ..Ma # Lot '
- Sigtoahtre ' °`'�'� . •
•
Edo K. •. 1,7 i i p Inv, 5 ' ', I --=-7 .
4 . . . ___
,....,........
C : `' ° S r i : DE ARTMENT OP BUILDING INSPECTIONS 4' , Mg _ -
INSPECTOR Main Street 'Municipal Building — I Northampton, Mass. 01060 e
HOMEOWNER LICENSE EXEMPTION
(Please Print)
DATE; 0f (
JOB LOCATION:
(Map) (Parcel) (Subdivision)
HOMEOWNER : . A m /L -(C
( ame & Address)
3 • - ' d , Or t .a ? - 3`1 57 II'-r 2
(Home Phone) (Work Phone
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, prov that the owner acts as supervisor. CMR780 Section 109.1.1
DEFINI.TION'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 b.e -
conside-red 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 buiadinq
permit: . .
As acting Construction Supervisor your presence on the. job site
will be required from time to time, during and upon completiori'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 f.V Li4"---1, 1 767, 77 -411‹
•
BUILDING. PERMIT # : S
•
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cb --3 O r o m
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Zoning
Miscellaneous Additions, Repairs, Alterations, etc. Tel. No. Alterations
e : ) NORTHAMPTON, MASS. 19 Additions
"`' APPLICATION FOR PERMIT TO ALTER Repair
�+�I � ' nn 1i Garage
X Location o Ferry CGv Lot No. �I
-Z. Owner's name ' t (^,' < TA i U!%v +%K a ddress 3 760 �r 4 iUr it
3. Builder's name Address
Mass. Construction Supervisor's License No. Expiration Date
91
Addition [ 0 X 16 1 e 61
5. Alteration
6. New Porch
7. Is existing building to be demolished?
•
8. Repair after the fire
9. Garage No. of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
)4stimated cost:-
)r a0V The undersigned certifies that the above statements are true to the best of his
knowledge and lief.
Signature of responsible appucant
Remarks
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This corm to be filled in
by the Building Department
Required 1
Existing Proposed By Zoning
Lot size 0i 6 0 0 0j(5-LZ
Frontage /00 ) O/j
Setbacks - frnnt :‘
1
- side L: R: & L: /5 R: . 2c 1j
- rear ` � .2
Building height ,
Bldg Square footage l D Q o
%Open Space:
(Lot area minus bldg
&paged parking) 0
# of Parking Spaces
#' of Loading Docks
Fill:
{ volume - -& location)
13. Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowl-•ge.
DATE: 7/ 71 APPLICANT'S SIGNATURE v.A �_-1 - -/
NOTE: Issuanoe of a zoning permit does not relieve an applioanrs burden to oomply with all
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission, Department of Publio Works and other applioabie permit granting authorities.
FILE #
\q
76 2 8 nag
File No. Zebt3
r
l iUNS
---- ' ZONING PERMIT APPLICATION ( §10.2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: PC( r I C- i G NOW Gt K
H.
Address: -1 r) I d RRl("f kQ /C Telephone: 5 O ?-- 3 ?61 J Rg-city7Y
2. Owner of Property: r� t
•
c . tOew A K
Address: ,) (' l cErry 137 Telephone: 5 - .3 et
3. Status of Applicant: X Owner Contract Purchaser Lessee
Other (explain): �f� ���
4. Job Location: _t I42t f�C J �
0765
Parcel Id: Zoning Map# Parcel# District(s): ,i,�- //
(TO BE FILLED IN BY THE BU ING DEPARTMEN )
5. Existing Use of Structure/Property r )f Lot
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
i t - ! e- Si • r 1' — D 7
L...)(1YJ Dier Co 01 UAcA-0 L()± ; Lukict, Abuts residents
hums (c a / x/O
7. Attached Plans: )( Sketch Plan Site Plan Engineered /Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special Permit/Variance /Finding ever been issued for /on the site?
NO X 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 #
9. Does the site contain a brook, body of water or wetlands? NO X 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:
(FORM CONTINUES ON OTHER SIDE)
Y
File # BP- 2000 -0345
APPLICANT /CONTACT PERSON NOWAK PATRICIA
ADDRESS/PHONE 37 OLD FERRY RD 587 -3959
PROPERTY LOCATION OLD FERRY RD
MAP 25C PARCEL 265 ZONE URA /1,v2
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c% ? 5
Typeof Construction: ERECT 10 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
A roved as presented/based on information presented.
!/ Denied as p resented:
�
t/ Special Pt and/or Site Plan Required under: § ' 2-, /® /d - A0, /J -A-
1,. PLANNING BOARD ZONING BOARD
Received & Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w /ZONING BOARD OF APPEALS
Received & Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w /ZONING BOARD OF APPEALS
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
v Permit from Conse . An Co ission c ,4: , - j��'
/�
J o
i
Signature of Building 0 ` icial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.