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.d = DEPARTMENT OF BUILDING INSPECTIONS 11 =_
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I fie / 2 (- )-e)2
(lipe
with a principal place of business/residence at:
•
5"---/ .."--7 ..---, (phone /') 5;5 4 0,9 r2_,
(strl/ci ty /stalcizi p )
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:
(1n_szuano Company) (Policy Number) (Expiration DaIP)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below vnho have the following worker's compensation policies:
(Name of Contractor) (Insuranc; Company /Polk}' Number) (Expiration Date)
(Name of Contractor) (Insurancc Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compan)•/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shod if necessary to loch & informaIIoo pertaining to all cop radors)
I am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE: pt=-se be amts the while homeowners who employ pcsom to do m- n:te s: constrnctioo or repair work on a dwelling of
not more than throe units in which the bony owner raids or oo the grounds ap`,rurtcnant tlxcto are not ecacridly coesidacd to be
employers under the worker's cempcisaiion Act (GL152�s 1(5)), applir rion by a homeowner fora liccasc or permit may evidcn« the
legal autism of an employer under tho Worionee Compensation Acr_
1 underztand that a copy of thin ehtcmnst may bo forwarded to tho Dcpurtmcnt of Ir.-Currie] Ancadrnb' Offroe of Laurance for the
coverage veificslioo and that f-ilurc to sccurc eovcTngc under soeJon 25A of MOL 152 C:111 lead to the impasitioa of criminal penalties
000iistmg of a fine of up to S1,500.00 ardor i>apaao®cni of up to one year Loci civil p.=12-flies in the form of a Stop Work Onkr end a
flea 0(5100.00 a day tgnimt mc.
Fora 67 -tm sae cure ooly
‘-'''''f-
41- P cr mlt N umber _ _— — _ -
��j Mlp " Lotrt --
i�1uue. of Licensee /Pcrmittee e
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ li
Name of License Holder : •i(/ � ' C %� 17 �1 J (3 6 /85
License Number
5 ri-e) ✓`r' l c r j a i ,,/ /o/24/03
Address Expiration Date
5'B¢.
Signature Telephone
'r -r ,: €€ 1 ,. M ._:... V Not Applicable ❑
f2o4oC
Company Name Registration Number
/6' /Q 4
Address Expiration Date
5 / A'S-h c ,a /,,/ Telephone ` 1- C83
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 ❑
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(sPIS Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition CF' New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: Y EX -1 14) O � .`' `t 1 Cn 12 - °P °'�2 3R
Alteration of existing bedroom Yes /( No Adding new bedroom Yes x No
Attached Narrative ❑ Renovating unfinished basement Yest' No
Plans Attached Roll ❑ - Sheet ❑
6 a N Z#tbi"isttdt d O Etirlitio t6 zit g h tit fig oh 1 tel6I.I0wi.i :
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
SECTION 7a OWNER AUTHORIZATION - TO BE COMPLETED ; WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ''
, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, i iC��� � r' Z n d , as OwnerI.Arti t
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 Owner{ -AAert 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: 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:
i I ing Department
t„ ' °; ;7 Main Street
PR 1 5 2 004 itoom 100
Northampton, MA 01062
' phone 413. 587 -140 Fax 413 - 587.1272 !
*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 o be c millet I by gaff ce el „ 3
c /ft-4 C ✓eJ Map a.,
/u / Zone k . pver[a, D.sirtcf;
Elm'St. Di5trlct GB bisfrict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /// �
✓� /' /. !� /i' � ��. �± // C 375/ C. ely J7 (.
Name (Print) Current M ilin Address:
yy S 8 g 2-
_ mss Telephone
Signature
2.2 Authorized Agen t:
eid i
Name (Print) Current Mailing Address:
Signature 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 (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) OQ °" Check Number 96 ( p This Section For Official Use Only
Building Permit Number: d" Date Issued:,
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2004 -1042
APPLICANT /CONTACT PERSON RICHARD DENNO
ADDRESS/PHONE 551 FLORENCE RD FLORENCE (413) 584 -0852
PROPERTY LOCATION 551 FLORENCE RD
MAP 37 PARCEL 001 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Fee Paid
Typeof Construction: DEMO & REBUILD ROOF 7/12 PITCH
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION PRESENTED:
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
_/', 2a0
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.
551 FLORENCE RD • BP-2004-1042
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 001 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- 2004 -1042
Project # JS -2004 -1566
Est. Cost: $9000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD DENNO 066189
Lot Size(sq. ft): 40467.24 Owner: DENNO KAREN H
Zoning: s:Z Arpj hcant: RICHARD DENNO
AT: 551 FLORENCE RD
Applicant Address: Phone: Insurance:
551 FLORENCE RD (413) 584 -0852
FLORENCEMA01062 ISSUED ON :4/29/04 0 :00 :00
TO PERFORM THE FOLLOWING WORK: DEMO & REBUILD ROOF 7/12 PITCH
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: 746% ry . House # Foundation:
`b Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:Or 7_ s/
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/29/04 0:00:00 962 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo