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-zm=— DEPARTMENT OF BUILDING INSPECTIONS •17411_____=.--
212 Main Street • Municipal Building
Northampton, Mass. 01060 as s's
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
(licensee/permittee)
with a principal place of business/residence at:
• (phone#)
(street/city/state zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy N •••• (Expiration Date)
Yalir I am a sole proprietor, general contractor r►r. homeowner •;,cle one) and have hired
the contractors listed below who have the following ••. .e s compensation policies:
poll‘ktzt)o-t--/ #
(Name of Contractor) (i isurance Company/Policy Number) (Expiration Date)
if
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all contractors)
( ) 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 while homeowners who employ pawn to do maintenance,construction or repair work on a dwelling of
not more than three units in which the homeowner resides cc oa the grounds appurtenant thereto arc not generally coosid«ed to be
employers under the workees ccsupensatMa Act(GL152,ss t(5)),application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Compensation ration Act
I understand that a copy of this atatemmi may be forwarded to the Daparta roi of Industrial Accident?Office of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
oom.istiag of a fine of up to S 1,300.00 andlor ithprisonment of up to one year and civil penalties in the form of a Stop Work Order and a
fine of 5100.00 a day against tnc.
For depsrtmentsl ufe onty
sitrAl Permit Number
' mapil Lot#
Si.•. •a : of Licensee/Permittee late
1
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
� y t 1,..' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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.
s
Homeowner Signature< _ v �
,(j
SECTION 5- FESCRIPTION Of PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
IDemolition0 Or Doors ❑
Accessory Bldg. New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: t et'f 1 ri �i a .SA e...Gf g
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes ZNo
Plans Attached Roll ❑ - Sheet❑
' t ®' `.} ,.11. 5 $ 0'IR ho sh ': rripleteith tfotaow
a. Use of building : One Family Two Family Other .S elG 1
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 N/ No. Is construction within 100 yr. floodplain Yes v--' No
j. Depth of basement or cellar floor below finished grade t ///
k. Will building conform to the Building and Zoning regulations? 'Yes No .
I. Septic Tank ` City Sewer ( �� nvate 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, M F 2Y L 11 l.1 Po Q D (LE I e t �: r'�r 1() , as Owner/Authorized Agent
hereby declare that the statements and information on the foregesing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name j
Signature of Over/Agent Date /V "O()
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
,�.,1 Building Department
?v v
Lot Size �/ / u i-
Frontage 101— // 6r-22
Setbacks Front g / ,,
Side L: R: ti7E
Rear Z/
Building Height c9-0
Bldg. Square Footage ^6.(p % g"9-- 07,5-Open Space Footage 1
(Lot area minus bldg&paved 11�
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:
Cityof Northampton `
�� OCT Builfng Department � �
` 2 ZOOQ
212 Main Street
Room t;_. s man 3 v
1 # ,t i1FD �' a r"':emF Flo 100 d� . A 6 � , s
t �a ` pton, MA 01060 a
phone 4 -1240 Fax 413-587-1272 &���h g -` �,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be+�onhpleted bye%e F
1.1 Pro. =rt Address: �,,,,
1 ;; zy
l '. 11 1_11- ioS Zone d � �
Y7vC
$1..District ` CB I Istrict
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
(�-)i-t. £//-f 1 `.,f A)0'"°_'/ `-('- _� 11e,)/`— "r 1('(-c c -it,--A: f it,-_,,-...,
Name(Print Current Mailing Address:
/ , f Telephone,4
, , , ,
Signature
2.2 Authorized Agent:
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 1, (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) $.��r"�C . Check Number i
This Section For Official Use Only
Building Permit Number:
` " 2/ -( Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0352
APPLICANT/CONTACT PERSON POLLARD MARY ELLEN
ADDRESS/PHONE 6 HEFFERNAN ST (413)585-8868 0
PROPERTY LOCATION 6 HEFFERNAN ST
MAP 11C PARCEL 006 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
/9b`b o25-
Typeof Construction: ERECT 8 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
��3 sets of Plans/Plot Plan
TH 'FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
•// Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Appro al hoard of Health . , Well Water Potability Board of Health
Permit from Conservation ission Permit from CB Architecture Committee
/0/61
Signature of Building O icial 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.
6 HEFFERNAN ST BP-2001-0352
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-006 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:shed BUILDING PERMIT
Permit# BP-2001-0352
Project# JS-2001-0572
Est.Cost:$2601.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 8189.28 Owner: POLLARD MARY ELLEN
Zoning:URA Applicant: POLLARD MARY ELLEN
AT: 6 HEFFERNAN ST
Applicant Address: Phone: Insurance:
6 HEFFERNAN ST (413) 585-8868 ()
LEEDSMA01053 ISSUED ON:10/5/00 0:00:00
TO PERFORM THE FOLLOWING WORK:E RECT 8 X 12 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/5/00 0:00:00 195 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo