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" I — — — -- i r. , , (....._,, ' 7 .----i, -1--- -i- t , : 1---- X ! !!!!!!! I • 7, '>--.... ... . " oss ' ' ' ',..',.,. 1 , e _ . • . 1 ; ''..r. , I . _ 1 , 'it-- C.... ' 1 c —1-------- CX) ZD • .) .....,, I . i r I ..„. I L-a . r _., — — ' N ..,... ■ —,,... The Commonwealth h o fas sacracserts —_ _ r; i 7.1 'i zt f'f 7 ? . ! f - 1..,..../....... ...., a ✓ . Office ce of Investigations rn 17",,,,Z.;...."—,,,, r e CL -- _ 4V:1 !I KJ ILL IL LV %L VL G� — Boston, MA 02111 -` _ 71'74w.mass cov'tha W Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers calicant Information Please Print Le6ibly Name i? u sin ess , Orear.imti on; Individua1;: ik[�(.tk. _L< Cst 66,,c40 . d r_.`.s: ?-15 / lily ("A" Ova ` p-ef t. 4, - ., , /^ cit S.�.t.,' Al Phone .re you an employer? Check the appropriate hot: T vpr of project (required): ��� i_ 7 1 am a employer with 4. 0 T a a general contractor and I f. T-1n4' 14?a$ (full anc.�or a rr_t+mw ) * have hired the sub - contractors I 6' env construction t 1 •y j 2. am a sole proprietor or partner- Iisted on the attached sheet. ' cmodelin4 f i 2. shi have no ernnlnver:s These sub - contractors have t R_ emolirinn f i working for me in any capacity. _ e Ioyees and have workers' I 9. Erzildi g addition cone. inst rauccoup. irtsurance.f I required.] 5. U We are a corporation acd its a U. iec.:ica1 repairs or additions requite:..] 3. ❑ I am a homeowner doing all work officers have exercised their 1 11.12 repairs or additions I myself. myself. o workers' comp. right of exemption per MGL 12. oof repairs insurance required.] ? c. 152, § 1(4), and we have no 13 Other employees. No workers' t comp. insurance required.] j *Any applicant that tie: k. box #1 zrazst. also fin oe:t the section below showing their workers' compensation policy iuu`orrr.a on. " Homeowners who submit this a*idavit indicating they are doing all work and then hire outside connactors must submit a new atticavit indicating such. +Cone aactors that check this box rrwsr attached an addiiional he showing the name of the sub- con-uset_o*s and state whether or not those en itzes have ern loyes_ if the sdb- .:ontJnws have e.noioveaa, they must provide their workers' comp. policy number. I am pro vidin' workers' compensation insurance for my ionfsespostir Below is the policy and job site information. 4 (fr ?W5 � , y-47 c 1 Insara. -ee Company Name: Ptef e�f a 4' 1 4 - CO chi N — Policy ; or Seif -ins. Lic.:: (44. -24 -- -2-40 -- 02-03S -ce Expiration Date: 3r62-(10 Job Site Address: 5Y 51 / e Ili tilt' f } DMA (Q City/State /Zip: Mil %O Attach a espy of the workers' compensation polity decialation page (showing the policy number and expiration date). Failure to secure coverage as required under Section 254 of MGL c. 152 can lead to the imposition of criminal penalties of a fne up to S1,50;?.0O andior one -year• inigiisorsn ent, as well az civil penalties in the form of a STOP WORK ORDER and a fine of up to 5,250.00 a day against the violator- Be advised that a copy of rhii statement may be forwarded to the Office of investigations of the ILA for insurance coverage verification. I do hereby cerrifiv and the pains and penalties of perjury that the information provfded above is true and correct. / ... i e •► Sibnatur . . 03,7 Date: > i/ Prone . ( du " ' ., - Of use only. D not ti'rite in this area, to be completed by cite% or town ofjlciaL i I Cite Or Town: Permirllicense Issuing Authority (circle one): I 1. Board of Health '. Building Department =. City /Town Clerk. 4. Electrical Inspector `. Plumbing Inspector ' 6.Other I Contact Person: Phone T: I • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: i sor: / Not Applicable 0 Name of License Holder : !�( lit _t QS ic J License Number d-c go/ A., fed 0 a 2,- tispi Addr-ss / Expiration Date A rk. PEP' _ - igna'ure Telephone 9. Registered Home ?c Improvement Contractor: l� / Not Applicable ❑ L 4 Lt u �' lc WC7 Company Name Registration Number RS go/ r,(1. r if Olt ; -- 7f I fie Address Expiration Da 6 Telephone J53" � (7 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 ❑ 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 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 I or .oning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature w N( • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing FA Or Doors Accessory Bldg. ❑ Demolition ® New Signs [❑] Decks [p Siding [❑] Other [❑] Work: Description of Proposed Q k f� / / pa r Work: C� -° Alteration of existing bedroom Yes )( No Adding new bedroom Yes j( No 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 CONTRACTOR APPLIES FOR BUILDING PERMIT Y( I, A (�_. / U c_ , as Owner of the subject property hereby authorize (Ui- L.. t_y-N to act on my If, in all matters relative to w rk authorized by this building permit application. 'gn wner Date , as Owner /Authorized Agent 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. ::zwneri9ent 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 L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot arca 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 Q DONT KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (3 DONT 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 g DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date issued: C. Do any signs exist on the property? YES Q NO I& IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: E. Will 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut{Driveway Permit %��� 212v Main Street SewerlSepticAvailability, \ ��i - Rbom 100 WaterJWell Availability Nortatfipton, MA 01060 Two Sets of Structural Plans phone 413 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans Other Specify, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION 1.1 PropertvAdd This section to be completed by office 5, / + ` , f 1 l? ) Map Lot Unit s Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record;_,... � l^� n �'CJsc h S 1.-)44.r--e d 13 `?• N5 'me (Pri Current Mailing Address: ) Telephone )� ) / , — 3 ignature / cf �7 2.2 Authorized Agent: ;cii.. (,)(,-/r e - (� Q P €/haw, o g ©ate. Name (P .nt) urrent Mailin Address: %±•� -A *„; t, d-s3 -9111' �- li) 32.16 Sig ature / Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Use Only completed by permit applicant 1. Building (a) Building Perm Fee acv. cv 2. Electrical # tit (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) #3C 7�* Check Number d .4. This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Build Date File # BP- 2009 -1022 APPLICANT /CONTACT PERSON RICK LIGHT ADDRESS /PHONE 25 BOYDEN RD PELHAM (413) 253 -9492 PROPERTY LOCATION 54 SOUTH MAIN ST MAP 23B PARCEL 081 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid N i0Q/19 Typeof Construction: REPAIR PORCH PARTIAL ROOF REPLACEMENT,INTERIOR RENOVATIONS, INSULATION /SHEETROCK &WIRING New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 056457 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date 1 '0 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. C.EF.D o . l I 5109 ulits oi : To ?LAPS PCLAV€( -0 BP- 2009 -1022 GIS #: COMMONWEALTH OF MASSACHUSETTS 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- 2009 -1022 Proiect # JS- 2009 - 001465 Est. Cost: $35000.00 Fee: $210.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICK LIGHT 056457 Lot Size(sq. ft.): 7492.32 Owner: TESCHNER ANNE F Zoning: URB(100)/ Applicant: RICK LIGHT AT: 54 SOUTH MAIN ST Applicant Address: Phone: Insurance: 25 BOYDEN RD (413) 253 -9492 PELHAMMAO1002 ISSUED ON:6/18/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR PORCH PARTIAL ROOF REPLACEMENT,INTERIOR RENOVATIONS, INSULATION /SHEETROCK &WIRING 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 6/18/2009 0:00:00 $210.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo