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• v04%. DEPARTMENT OP BUILDING INSPECTIONS z
j
212 Main Street • Municipal Building
Northampton, Mass. 01060 fi
WORKER'S COMTENSA'I-'ION INSITRANCE AFFIDAVIT
l
(I io n oci ri nitt °e)
with a principal place of businessIresidence at:
lee471A, Dior (hone=:
(strcct/city is,. tc'zip)
do hereby certify, under the pains and penalties of that
( ) I am an employer providing the followin vorhe, s compensation coverage For my
employees working on this job:
(Insurance. Company) (Pork. Numb (E). tion Date)
( ) I am a sole proprietor, general conm ctor OF 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 Comoaav/Policy Number) (Expiration Date)
(Name of Contractor) ([nsurancc Company /Policy Nainber) (Ex;:iranon Date)
(Name of Contractor) (Insurance Comr:a_r;y/Poticy Number) ( Expiration Date)
(attach adaltional Occt if r.crczar: ;o lnc;nc ?c i_fcC ce cc: patain:cr t:; all r_ - :•)
I ton a sole proprietor and have no one ' for ale.
( ) I am a home owner performing all the v or'.d: myself.
NOTE: ptc sc be atvl c tlha: tt ilc I-,(IncO•ir_t1 t4;0 CI! oy c.l-au:!caaact, cr ::pair o: ?: c:, : ttcl!i c.
110(1210(c th u (hrco unita in w dt he l vuirs rcaid._-i cc oa fi O _ 3 appurtcc r1 thccto O t DCA Eczrrally cr td to
erptoyc-3 u_rrScr the tvorkcfc cct c ctixt Act (GL1 c11(5)), ap•;.t :_ _ticn bye hotncottncr for Lcv=c ce per ;:i : 'nay
legal ctainz of an egployor under tho Wodccle Cocnpar.+tion Art
I understand thei i copy of thi, Etatrnscnt may bo for to tho 13c5xertoccnt of Induc:rie] , 5cnt? Offico of t,ruu.rcr fort the
covcrl vcriTicafioo And that failure to centre coverage under s.ecticn 25A of MCI, 152 can cad to tho imposition of main.! per—Attics
oomuting of n ftnc of up to S 1500.00 eni'oc imprisoccanci of up to on- } ccr AM civil pcni Itia in 'tic foctn of e Step Wank Ord,n" and a
fin, or S100.00 a day tglinrt trr_
_ For u t r vatel ur o only
•
• permit Number
Map• /
rY Signaat of L sce/Pcrmittcc
SECTION 8 ,CONSTRUCTION SERVICES
8.1 Licensed Construction S ervisor: Not Applicable ❑
Name of License Holder : Air #4,97 9J-7i5 9 •- License Nu ber
pa gab �e it/ / . / 7 Qs
Addre . Expiration Date
`J id - S37 0 )
Sign. re , Telephone
Onl' - ere 'Nomeflmpr'ovement Cififiactor ; , ,,, Not Applicable ❑
Company ame /
/1ii9' Registration Number
ro &, /c P LeeJ fi4to,o s _ j- _
Address Expiration Date
Telephone ....5
- -"
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 ❑
^gar -x:« - I i - =a ss f �+. ` *.�"` ..�..
i i' T ome owner memption
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 fly 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 [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: _ - ,ai /,3,Cc' !y�N 12i% � �-S ,�ti _ � " ! ' ,__pi2 . 4-1r
Alteration of existing bedroom Yes No (7 Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ Sheet ❑
6a. If New . hou"se:and = or-'additien: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. Mascheck Energy Compliance form attached?
h Type of construction _
Is construction within 100 ft. of wetlands? _ Yes No. Is construction within 100 yr. floodplain Yes Nc
j. Depth of basement or cellar floor below finished grade
k. Wili 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, _ )c� — as Owner of the subject property
hereby authorize li q YZ N y - _ to ac; or
m' behalf. in all atters relative to work authorized by this building permit application
WOW
�+ Signature of Owner Date
I, is d.eve , as Owner /Authorized Agent
hereby zeclar + at the sta ) m ents and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed finder the pains and penalties of perjury.
. 4 _ ,e.,4,e Print Ne-
Signature f Ow r 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 I.: K: L: R:
Rear
Building Height
I _
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:_
— — ,,
ri City of Northampton Status:- ut s of Permit p � °` ,i � r
Building Department Curb Cut/D versa e k . .. ,
212 Main Street Se er/,SepticAvai a - '-`'- : '�. k ,;
Room 100 Water /Well li � ' °
Northampton, MA 01060 Two Sets of=S ans t ru f , s' c � tur L al ' ans � 4 , ,n -
L �Y: 254 :' ,,,t ,,,, - K
phone 413- 587 -1240 Fax 413 "587 1272 Plot /Site = P - t � . f
Other Specify $ � ,„ , ,I b
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
Map _ Lot Unit
S5P ry kec
Zone — Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
H
2.1 Owner of Record:
, j0C . Cait<
' ' _o& 5/ f,<;Spe_je /4/.7: 4 ." .0 .o . ' b elOtot
No lie (I \int) . , . ' rent r'�a��l1n; ,address:
2.2 Auth rized Agent:
1 ,A;c; MeAe
I Name iP 4 ntk../ ,',:1[ 1F, address 6 %21't 7777
i Sionat.:r!
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
tem Estimated Cost (Dollars) to be I Official Use Only
com•leted by sermit applicant
1. Uuiidi (a) Building Permit Fee
_ (k ti,T Total Cost of
1 construction from (6)
i 3_ Plumbing I Building Permit Fee
_ fF.ni' ( IiV,AC)
5. Fire Protection ,
6 I otal = C. 2 + 3 + 4 + 5) 1 _I C,neck Number _/I
This Section For Official Use Only
Building Permit Number: Date Issued: — — --
Signature:
----- - - - - --
Date
Building Commissioner /Inspector of Buildings
s*PiasPrzcr AVE BP- 2003 -1141
GIS #: COMMONWEALTH OF MASSACHUSETTS
} . g :24 ,.1,26 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP -2003 -1141
Project # JS- 2003 -1802
Est. Cost: $9500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Craig Marney 102112
Lot Size(sq. ft.): 9888.12 Owner: BROOKE WITTER F &
Zoning: URA Applicant: Craig Marney
AT: 53 PROSPECT AVE
Applicant Address: Phone: Insurance:
P O Box 128 (413) 586 -5512
LEEDSMA01053 ISSUED ON :6/13/03 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS & 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: Receipt No: Date Paid: Check No: Amount:
Building 6/13/03 0:00:00 3475 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo