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24A-149 VO 5NV7d 01/02/2008 11:45 1 -413- 532 -8571 CODES&INSPECTIDNS PAGE 07 The Commonwealth of Massachusetts Department of industrial Accidents t E .=e �t Office of Investigations =m= - 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumber A lieant Infornmation Please Print I', : iblh= Name ( Business /organization/individual): ., i „mt. Address: /0 y d /Von -/'k ciree _ City /StatelZip � ' ` /A 1 /T4J Phone #: V /3 —c:Qof 988D _. Are you an employer? Check the appropriate box 'ape of project (required): 1.0 I am a employer with 4. 0 i am a general contractor and 1 employees (fall and/or part-time).* have hired 6. ❑ )3 coastructioa 2.0 I am a sole proprietor or partner- listed on the attached shat 7. L�J xemodeliag ship and have no employees Y hose sub contractors have 8. 0 Demolition working for me in any capacity. etaployces� r ve work 9. ❑ Building addition [No workers' comp. insurance required.) 5. ernPVe are a corporation and its 10.0 Electrical repairs or additions 3.0 Tam a homeowner doing all work dilcers have exercised their 11.0 Pltaobing repairs or additions myself [No ' gip. right Of exemption per MGL 12.0 Roof repair t c.152. i 1(4), and we have no tnsuranee required] employee * [No 1313 Other comp. insurance required.] *Any syphomt ttiatcheeks box II roust also fill out the section below riemt*rtg their *Am' compotsidiat policy iafnrmttian t lio:,saw acia wAso submit Ibis affidavit iudianipg they rte doing aM work old then hire outride connectors oast Merit a new at)davit escheating aveh. kentractors that cheek this box awn .meted m additional duct slowing the name elate sobesaaetaw and me whether*. not that entities have . employeet. If the sabeont:actr es have employees, they must provide their wottars'temp. polity swd . I am an employer that is providi ng workers' compensation insurance for any employees. Below is the policy and job site information. J I n s u r a n c e C o m p a n y Name: 'Vet' ( e 5 I N 5v { c e - - _ • .. Policy # of Self -ins. Lit:. 4: GR? B ihTi S S 7 Facpiration Date: 0 B/0020/0 Job Site Address: , City/State/Zip: Attach a copy of the workers' compensation polity declaration page (showing the policy Dumber tend expiration date). Failure. to secure coverage as requited !under Section 25A of MGL c. 152 an lead to the imposition of criminal penalties of a floc up to 51,500.00 trod/! x one-year imptisonment, as aeell as civil penalties in the fauns of a STOP WORK ORDER and a One of up to 5250.00 a day against the violator. Be advised that a copyof this statesoonanay be forwarded to the Office of lnveatiastions of the pAtr insurance eoveram verification. I do hereby ere& - the pa@es tad para!tta of perjury that theLaforare:los prodded above is trite oil correct. • CC1 .. i a ate: • • e #: TAW O f f i c i a l u s e o n l y . D o n o t w r i t e I n t h i s a r c s , t d be conrpkted by lily or tour[ official City or Town: • Permit/Meese Issuing Authority (dada one): i. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other • Contact Perron: - Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder — 579 k 1 CI ►1 dr-7 C S 09395e . e License Number Go- > ree t" 4- - 3479Atva Address Expiration Date j/1..._im7, Vi 3 ;d-r v Signature Telephone 9. Rea+stered Home mprovement.Contrac tOr:. ' Not Applicable ❑ gave 1 Pc'S i,v1/4_ Ut 4 7,;;/I /Kc r 15 %/D. Company Name Registration Number /Pi d� f l �` �S ri 1 t2iVaain Address [s Expirati n D to Telephone 4 7 1 75 . 7 6 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 buildin permit. Signed Affidavit Attached Yes No ❑ 11. — 130ilie Winer Exemption 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) [ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [[:3 Siding [❑] Other [❑1 Brief Description of Proposed 11 i-� L. Work: � � ° r^20�P ><� 5T � t�rc '{ �o `C k 1 (' �jc / , ( W( 5 Al J i' - meat," Alteration of existing bedroom Yes N o / Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes %." Plans Attached Roll - Sheet sa If New house and or addit = e1issti hau comD1ete the foitowinc : 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? i Fire places or Woodstoves Number of each Mir g. Energy Conservation Compliance. Masscheck 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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ;3 J / /IA I, 4-L !- Joe 6 f4e r , as Owner of the subject property �- hereby authorize — J!J k•_ 1 a 4J to act on my behalf, ' all :tters m1 -five to • k ithorized by this building •ermit application. Signature of Owner a • ate I, 7591- LA 4A et/ f , as Owner /Authorized Agent hereby declare that the statements i d 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 1 Signature of Owner /Agent , Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size - - -__ Frontage Setbacks Front Side Rear.. Building Height Bldg. Square Footage : \ , Open Space Footage o (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 0 DONT KNOW 0 YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page, and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q IF YES, has a permit been or need t be btained fro the onservation Commission? Needs to be obtained 0 ained , Date Issued: C. Do any signs exist on the property S Q 0 IF YES, describe size, type and ocation: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 0 IF YES, describe size, type and location: E. WIII the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • City of Northampton ,1 � � � ', b` i x k t 1 ^�Q1Q Building Department 4 w � $ -, ti ��, ? Main Street ., 2 _s: i -"Y ;d wo s , ; . ROOM 100 � �I , � - Northarx�ptbn, MA 01060 kit ' . . µ ,7 i* M ° . phone 413 -587 -1240 Fax 413 -587 -1272 = J4 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office + �2 /"e /- ��f Zone Map Lot Unit Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 05e � l- re ',- a -; _ M ; �, fk A--le ,� � Name (Print) Current Mailing Ad ess 4N11LY Telephone Signature 2.2 Authorized Agent: Jot-- /_a,. ' � � My AID - k 5 ��°P Name (Print) Current Mailing Address: eel_ // g y - 9s R ■ Signature / f Telephone SECTION - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building F 00 (a) Building Permit Fee 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) Z - 7 2 , C p Check Number 06-5--. This Section For Official Use Only _ Building Permit Number: Date Issued: Signature: Date Building Commissioner /Inspector of Buildings File # BP- 2010 -0811 APPLICANT /CONTACT PERSON JOHN LANDRY ADDRESS/PHONE 104 NORTH ELM ST NORTHAMPTON (413) 204 -9880 PROPERTY LOCATION 22 NORFOLK AVE MAP 24A PARCEL 149 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Paid �O6 �l� Typeof Construction: REBUILD FRONT PORCH (SAME SIZE) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 093450 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF MATION PRESENTED: t 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 ...� 3JIj16 Signature of Building Official Date 1l1 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. 22 NORFOLK AVE. BP- 2010 -0811 GIs #: COMMONWEALTH OF MASSACHUSETTS Tti 4 t� 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 -0811 Project # JS- 2010- 001193 Est. Cost: $6340.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 8058.60 Owner: HELMUTH PAUL J & JOSEPH GREER Zoning: URA(100)/ Applicant: JOHN LANDRY AT: 22 NORFOLK AVE Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMAO1060 ISSUED ON:3/19/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD FRONT PORCH (SAME SIZE) 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: FeeTIT Date Paid: Amount: Building 3/19/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo W , .. . 22 NORFOLK AVE BP- 2010 -0811 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 149 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 -0811 Project # JS- 2010- 001193 Est. Cost: $6340.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 8058.60 Owner: HELMUTH PAUL J & JOSEPH GREER Zoning: URA(100)/ Applicant: JOHN LANDRY AT: 22 NORFOLK AVE Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMA01060 ISSUED ON:3/19/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD FRONT PORCH (SAME SIZE) 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: ck rd Rough: Rough: House # Foundation: ��✓l Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: 9 -i�-/ Q a N THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE _ : Certificate of Occuoan �� �r ature: FeeType: Date aid: Amount: Building 3/19/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo