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DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street • Municipal Building
Northampton, Mass. 01060 r''`
WORKER'S COMPENSATION INSURANCE A.FFIJ.)AVIT
e
(lice 1p ittee)
with a principal place of business/residep at`.
��� �'�°�✓�. � d'� t,, / ,1 s (p bonell),5 ej -
(str icity /staichap)
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:
( Insurano Company) (Policy Numbcr) (Expiation Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hued
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 Daie)
(Name of Contractor) ( Insurancc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(mach additional sheet ifnoccssary to include information pertaining to all oocense.ors)
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 wttilo homeowners who employ persons to do rr* O*tca , oxi>:ruction or repair work( on a dwelling of
not morn than throe units in which the bonxowner midi or on the grounds appurtenant thccto arc not generally considered to lx
employers under the worker's cocapassatico Act (GL152,sa l (5)), application by a botnnowtrr fora license or permit may evidence the
legal cud= of an amployoc under tho Wockeet Compemaisoa Act.
1 understand that a Dopy of this statemcnt may be forwarded to tbo Devartmont of Industrial Ancdomd' Of5oo of 1nsur,<o00 for the
coverage ve iflatioo and that fat= to aware coverage under section 25A of MOL 152 can kid to the imposition of criminal Penalties
000sistiag of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of n Stop Wort; Order and a
Ciao of S 11X1.00 a day against toe.
For dcputl uac oily
Permit Number •
Map# Lot #
Signature of Liccnsce/Permiutx Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ? e,
License Number
.fig / gi F� ,7 ; �-' - 1,5,E
Address Expiration Date
f
/- 0 /
Signature Telephone
- _ W a 1s s e �'Vww v_wi s o s tsr�,, ,.. u,.. '11 Not Applicable ❑
® c:i4 i / Zu 4"66
Company Name Registration Number
� A'
Address Expiration Date
Telephone.` e55
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 ❑
` i f f
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 presencepn 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
w
i
,SECTION 5 DESGRrT F P�O[ OROPOSED ' WORK(check '. altap,plicable)
x k : ...�. , it a"w , �d �R u Y »'�.b i- .mss .. .. »,,. , .... - T .... .,,.,, , v, ;. , ,».
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Door
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: ' d / " . 0s97
Alteration of existing bedroom Yes - _ No Adding new bedroom Yes > No •
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet 0 i A
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
• S CT10,t 7A OWN F A0t ORIZATIO I TO BE COMP1_EI.ED WH
oWN s AGENT" ORnc0,14/ AGTOR APPJJES FO GUtU31NG EN ERMlT
I j 2 } (t -1 `�� °� H . .• , as Owner of the subject property
hereby authorize J - C/ h ' it-o to act on
my behalf, i II matters relative to work authorized by this building permit application.
/3 /Y280 i
Signature of wn t ‘ Date
I , o - ) ,), ;+� , as.Cm rer /Authorized Agent
hereby declare th 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-ewer /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. 1 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 i
No
IF YES, describe size, type and location:
•
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I,
City of Northampton � �'
Building Department , � '
21 2 Main Street
Room 100!
N ortham pton MA 01062 � 1
ph one 413 - 587.1 Fax 413-0-8 7 127
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I A /
SECTION 1 SITE INFORMATION !'
1.1 Property Address: b h[S set #I "6",i. � a elect '-- - ' -
� r ��
i s + /
SIC[ �C.�[ �/1 � C M a . , , Unit
L. a ,
f SECTION 2 - P ROPERTY OWNERSHIP %AUTHORIZED AGE NT jut. 3 2009
t
2.1 Owner of Record:
C-4 cii,/, A __ / /
Name (Print) Current lyl� ing Ad s: ?a,
CI
_ Telephone Itoi
Signature /
2.2 Authorized ed Agent:
/gy Jd a,Q �� ,�/� cr �,,
Name (Print) Current Mailing Address:
Telephone
Signatu re
SECTION 3 tSTIIVIATEf3 CO NSTRU C TIION:COSTS
Item Estimated Cost (Dollars) to be offi Use Only
completed by permit applicant
1. Building �� (a) Building Permit Fee
2. Electrical (b) Estim bf.
Construction .
ruifrorn (6)-
3. Plumbing Bu�ldmg`1?ermit Fee
C)
4. Mechanical (HVA
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) check[uhtiber
This Se Fo Official Use Only
Buil Permit .Number: Date Issued_
Signature
Btldtng sipnerlln,§pgc tor of�utltltrg Date
•
. - T BP- 2010 -0044
GIS #: COMMONWEALTH OF MASSACHUSETTS
Aitap:mock: 24) :188 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 # B P- 2010 -0044
Project # JS- 2010- 000056
Est. Cost: $35.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10802.88 Owner: GRAHAM JEFFREY J
Zoning: URB(100)/ Applicant: GRAHAM JEFFREY J
AT: 41 JACKSON ST
Applicant Address: Phone: Insurance:
41 JACKSON ST
NORTHAMPTONMA01060 ISSUED ON: 7/15/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FRONT DOOR
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 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo