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- � DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060 frr s'
WORKERS COMPENSATION INSURANCE AFFIDAVIT
I, GA o yy hts
•
(liccnk y/pcFmitree)
with a principal place of business/residence at
��ezZvee)ier /arts 4'Z
Q /(phonei')
(str 1c/
c (city /stazip
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Police Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below wbo have the following worker's compensation policies:
(Name of Cont. - actor) (Insurancc Cornpany/Polic Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) ( Insurancc Compan y/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (EXPiradon Darr)
(attach additioml sheer ifnaocss.uy to include information pertaining to all ooa+sn.o:s)
j I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: please bc aware that whilo homeowners who employ pc soar to do Saeau7ivaac`e� atium, t coosruction or repair work co ■ dwelling of
not more than throo traits in which the homeowner resides or co the grounds appurtenant thc•ao arc not generally 000sidcrcd to bc
employers under the worker's cocnprssatim Act (GL152,s31(5)), application by a homeowner fora license a permit may evidence the
legil &t am,: of an employer under tho Workoh Compensation A.
1 under:tind that a copy of thine .t :met may be fog-you-dal to the Departmcot of 1.v4. Ancient a Oflioo of Iir a woo for the,
coverage verif esiioo and that failure to secure coverage under section 25A of MOL 152 can lead to tho imposition of criminal penalties
000sistiag of a fine of up to S 1 ,500.00 and/or improo®cat of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S100.00 a day against me_
For departrocceal tsae only
Pcrmit Number
®�� Maps Lot #
Signature of LtacnseeJPcrmitiee e
SECTION ,8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder : ./r l '% .-g1! %z - 2:a. )7 it 0 Zi5/" 89
License Number
5 ane) �. G /647_ /d /.2 VA/
Address Expiration Da
4 - c 8,c
Si Telephone •
1 ',
,4444:411.1T1ifgliliiiPAVirdktifOinTittkirittia0114, Aife- Not Applicable ❑
act i zalo
Company Name Registration Number
S'5 J Ze ;" z t e ?F/ - 2 /6YS
Address Expiration Date
Telephone - r
SECTION 10 WORKERS' COMP,ENSATION;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 ❑
iSAY 0
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 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 tiie 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s )ari Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: E-4 e10 £'jduiJ 74'1' 61 4�j
Alteration of existing bedroom Yes '( No Adding new bedroom / Yes No
Attached Narrative ❑ Renovating unfinished basement Yes -L No
Plans Attached Roll ❑ - Sheet ❑
. ', ` t " ®.. f: c ` s t (lff e. Mitt : qv, 1
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
SECT101 7 UWNEI AUTHORIZATION TO BE CQMPL WHEN
OWNERS AGI: CONTRACTOR 1PPI IES FOR Ul SIG PERMIT
.►� , as Owner of the subject property
hereby authorize 7/4 h#?!) to act on
my beh . n -II m. ter relative t% or •uthorized by this building permit application.
!� 4`
Signature of Owner j Date 1 —^ — - p Q
I, e r,4 )14- it , as 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 Name
Signature of Anwe /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
1 A . �
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:
•
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Building Department
City of Northampton v, .• - � ' " � w
� . ,k
ric) 21' Main Street „:' '�� ' -�
; oom 100
0 No MA 01062
phone 413 587 -1240 Fax 413 - 587 -1272 �, �
. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
•
A , /
SECTION 1. -SITE INFORMATION , ,, '
a his O o t)e Om l . ' ff[ce - ' h
1.1 Property Address: ., 4 �� ..
do 7 /IAd 4) ‘C.72. a�Map „ � Lo �� 1 ��
./ ,e j O : ;O r e . a e Vet"la„ it ., � a
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3
»Im �tz x 1 �� b`ISt r �, % ' ' #k
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SECTION .2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
`.p� C ELL.R h tI C 6 0'37 ez S i
Name int) Current Mailing Address:
. / / _
►� Telephone / ^�
Signature ��b ® a
2.2 Authorized Agent:
�oA 7)o h 17 6 .S 3 7 � �o � c h cv `7al
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIM 3 CONS TRt CTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Est ated Total os of P., >.:
Construction'froni".(6) .
3. Plumbing �' Bullding`Perniit Fee
,
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4 +5) �� t . e J CheckNurnber
'This Section . For , official Use Only
w,. 3rt�Y,
Buil Perm Nu mber, Date lssued_'
Signature
.::, uildi'ng Cpmmissipnerllrtspec#prpf B4ildings - Pate
•
m.
File # BP- 2010 -0670
APPLICANT /CONTACT PERSON RICHARD DENNO
ADDRESS/PHONE 551 FLORENCE RD FLORENCE (413) 584 -0852
PROPERTY LOCATION 137 WILLOW ST
MAP 23C PARCEL 061 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid s ,5
Typeof Construction: ENCLOSE EXISTING BREEZEWAY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:,
Owner/ Statement or License 066189
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOgMATION PRESENTED:
i./Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
t/i /i 0
Signature of Building Official 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.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
137 WILLOW ST I BP- 2010 -0670
GIS u: COMMONWEALTH OF MASSACHUSETTS
ap:Block:23C -061 ( CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0670
Project # JS- 2010- 000979
Est. Cost: $6000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO 066189
Lot Size(sq. ft.): 91911.60 Owner: MCGRATH PATRICK J & ELLEN L
Zoning: URA(100) / /WSP Applicant: RICHARD DENNO
AT: 137 WILLOW ST
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584 - 0852
FLORENCEMA01062 ISSUED ON :1/19/2010 0:00:00
T() PERFORM THE FOLLOWING WORK :ENCLOSE EXISTING BREEZEWAY
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 1/19/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo