25A-131 (4) « The Commonwealth of 7lassachuse s
" _ _ ' ' Dspcz t neli': of' I'zd rstr ial.Acci. errs
.s. ' . `- Office of Inv estig arzoizs
_ 600 Washington Street
-= Boston, ?414 02111
x•x'.mass.gov /dia
Workers' Compensation Insurance davit: Builders/ Contractors /Electricians /Plumbers
D0 ricant Information Please Print Leo
._ .;‘
Name ( P. usinessiOrzanizat:onAndividuaL: -...' \ ± 1^' ",,1 ,,t ;'.:t.t ` ; ' ?. . '' —
Address: — r.� I: - .,: ', - I (- ,, ;
Cit F '" L eL L ., ‘ a., t-- -• €`°A. t )i C'( Phone #: `4 'J 1 - ' ' 4 ' ,..;� -� i
Are you an employer? Check the(appropriate box:
1 Type of project (required):
4. I am a general contractor and I 6 ❑ New const action
1 am a employer with ,�.. ❑ C
employees (,full and/or part - tune).* have hired the sub contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeimg
ship and have no employees These sub-contractors have s. n Demolition f
working for me in any capacity. employees and have workers'
P 9. Q Building addition
[No workers' comp. insurance comp. insurance.<
required.] 5. ❑ w e are a corporation and its 10.0 Electrical repairs or additions
3. CI am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself o workers' co ma. right of exem p er MGL
[ 1 _ ❑ Roof repairs
insurance required.] ' c. 152, § 1(4), and we have no
13.0 Other
employees. [No workers'
comp. insurance required.)
*Any applicant that checks box =1 ants: also fill out the section beiow showing their workers' compensation policy inforrration.
` Homeowners who subnm this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub - ont: actors and stare whether or not those entities have
employees. If the sub - cant - actors have e:rmtoye =, they must provide their workers' comp. policy number.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job sire
information. /� �y f
1 Company Name: `` AS5 n LIAT�Q' EAllt °here... P I , v(A �lc. , La _
Policy = or Seif -its. Lie. WCG so 000 woo 1 2_0P Expiration Date: es 125/11
fob Site Address: VI VA -Ake - City /State /Zip: N) T (4V l T 2 `"
Attach a copy of the workers' mpensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up, to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DL". for insurance coverage verification.
1 do hereby cer tiff• under the pains and penalises ofperjury that the information provided above is true and correct.
Signature: 1 7 J Date:
Phone e_ f ; .. '
r I
1 0,r7 cial use only. Do not write in this area. to be completed by city or town ofciaL
City or Town: Permit:I icy lse
I
Issuing Authority (circle one):
Board r t- Clerk T tri 7 r
� 1. t7c:lyd of Health 1 . Building Je^'1rii :.e:lt 3. CIT_ti ",'TO�yii t_,e: n 4. Electrical Inspector 5. Plumbing, Inspector
I 6.Other
1
i Contact Person: Pone .-:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 3 ecC c5 _
License Number
3 Z ? fl E Fween vn.4 • _ _ G 5 °S 315
Address Expiration Date
�s + + 584 C `16111
Signatur \ Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
0(ZZ
Company Name Registration Number
Address Expiration Date
?3Z ?lht__ 5t Fl.DeetAcc...- t 14 Telephone S g 4 (02.q
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 --jid No ❑
11. - Home Owner 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 1083.5.1.
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 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning i
This column to be fihled in by
Building Department �
----'----------- --------�------ r
Lot Size , �__-_-- ----�----- �----�---------�'�-
.__ --_ -_-._-___ - ' ---___---' -_'
Frontage i_______________�'_____________ _ -�--
Setbacks Front • � - `
-__ ,...
- � --- _--
Side L: r - - - D:' - . L:L___] R: _
r - - ----'
Rear ;___—/ ' ---�
Building Height ---- - / �- ' - '
16 � ( ( ' `_ _ _ - ' - '_
Bldg. Square Footagr /' r --'- . ---
_ _ _ / . � ,__ _� �_ -
Open Space Footage _ -- % � —_'
(�,ao�m��mxnup�o '_ i !-_ �-` [-- � ' `
parking)
� - __ �_- —_
L
#ofP�d�S�� �'- `-�
Fill: - - - ��' - --- - - - � -- -- - - -
� i '
(vviumc m Location) , ____
A. Has a Specia Fi "ingev.: been issued for/on the site?
�� DONT 0 YES 0
NO v�� KNOW �~ ��/
IF ¥ES, date issued:
. __________!
IF YES: Was the permit recorded at t ' R"jstryofDeeds?
NO �� »�\ ��
DONT KNO YES ��_
F - --
IF YES: enter Book Page / and/or Docunxent#
' . ___� � [--_--
_
�� ��
(2) B. Does the �tecontain a brook, ""dyofwo�ror e{bands NO �_� DONTKNOVY «^� YES �_�
IF YES, has a permit bee or need to be obtain i from the Conservation Commission?
Needs tobeobt�med »�� Obtained x~~\ Date --
«�� �~� , 'L -___-1
C. Do any signs exist o he property �� �� � YES �_� NO «��
r - --- '----- ---------------------
IF YES, describe ize, type ! |
' ' ' / __-
D. Are there any ` oposed changes to or additions of signs int-nded for the property 7 YES 0 NO 0
` _
|F YES, d' cnbe size, type and Location: 1 |
________ ___. .. ___________________`
E. Will the uonotrucUon activity disturb ( ring, gradingexcavation, or|hng) over 1 acre oris it part of a common plan
that will disturb over 1 acre? YESK } NO K �
�� ��
IF YES, then a Northampton Storm Water Management Permit from th- DPW is required.
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [In]
Brief Description of Proposed ( t
Work: �
e.UACe char- vJf eSc-e 55 (,J1in80v.) Av'A re c /E' sw--e.
Alteration of existing bedroom Yes 7 No Adding new bedroom Yes x No R-5 t:A
Attached Narrative Renovating unfinished basement ` Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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. 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 ( C ONTRACTOR APPLIES FOR BUILDING PERMIT
1, . r\ : t "1e.iCr bv' bte L� (AA %A -- , as Owner of the subject
property 1 3 a�
hereby authorize J e... v 4�
t o my behalf, in II m tters relative td work authorized by this building permit application.
,e, ,
Signature of Owner Date 1
s
I, J e-r- y . .--( Z O * \ , as Owner /Authorized
Agent hereby declare that thb 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.
Z e.Q4 -. „ V, ° (r
Print Name
,Ax/41 L ���� 5 1G \
Signatu n . -nt Date
,
i malli.g...11
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Department use only
City of Northampton Sta us o Permit
f ' Building Department 6urb7eiff/Dr4ewa l fe rt t4-
NAY I
9 I 212 Main Street Sewer/Septic vailabiil d?:. - h
Room 100 WaterlWe A vadabiIity
of PT
OF N G ia n - Northampton, MA 01060 Tw�Se sAf Stru Ural fans y "
• 413 -587 -1240 Fax 413- 587 -1272 rtfSi�PJans' 4,
Otf te
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
t - 1)141'aWC. Map Lot Unit
. l0 I - y m � Zone Overlay District
I\ t e` Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print % Current Mailing A ress:
ynt\
Telephone
Signature
2.2 Authorized Agent:
3-+e fT *-," OIT_ PIN ' i " t.. -C'-
Name (Print) Current Mailing Address:
'
G v�
� 1
Sign: � a Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from O
3. Plumbing Building Permit Fee Cr
4. Mechanical (HVAC) a
5. Fire Protection 2, W
6. Total = (1 + 2 + 3 + 4 + 5) r 9'56 — Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: /2
Building Commissioner /Inspector of Buildings Date
51 DAY AVE BP-2011-0955
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A - 131 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP-2011-0955
Project # JS- 2011- 001561
Est. Cost: $1250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 39683.16 Owner: MIHEVC NANCY T & DEBORAH KEHNE
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT: 51 DAY AVE
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584 -6251 Workers Compensation
FLORENCEMA01062 ISSUED ON: 5/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE FIRE ESCAPE & REPLACE DOOR
W /EGRESS WINDOW
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 5/19/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
51 DAY AVE BP- 2011 -0955
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A -131 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0955
Project # JS-2011-001561
Est. Cost: $1250.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 39683.16 Owner: MIHEVC NANCY T & DEBORAH KEHNE
Zoning: JTRB(100)/ Applicant: JEFFREY BOTT
AT: 51 DAY AVE
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584 -6251 Workers Compensation
FLORENCEMA01062 ISSUED ON:5/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REMOVE FIRE ESCAPE & REPLACE DOOR
W /EGRESS WINDOW
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: 0 Y: -4 --Z 11 c f
THIS PERMIT MAY BE REVOKED BY THE CITY OF ►'ORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE • � •' � ;N ,77 ,..7 ,..7 ) � �oti�tL
1:
Certificate of Occupancy , . nature:
FeeType: Date Paid: Amount:
Building 5/19/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner