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32C-115 (3) ''' i-stWIp2, ��� �° (rxf r rif Nori1i&mp±un ► _# wig:• Jv:g __� 1_. 04174.0! j3iassacElusells =_��_ V � DEPARTMENT OF BUILDING INSPECTIONS E.4-11:44-=-4-- 212 Main Street • Municipal Building 'a 4—S • Northampton, Mass. 01060 r WO •. !'S COMPENSATI( INS C.E AFFIDAVIT I, �It4/- /Od G (licenser/permittec) with a principal place of busines reside%• - at: Al l 'efibr 77v7775- i i hone## -6-3,3%/ street/city/state/zip) 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: (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or 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 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 shoot ifnccemaary to include information pertaining to all cootrac ors) dam 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 homcowvers who employ persons to do maintenance,construction or repair work on a dwelling of not more than three units in which the homeowner midst or oa the grounds appurtenant thereto arc not gaoCrslly considered to be employers under the worker's.onmpansatica Act(GL152.,as 1(5)),application by a homcoweer for a license oc permit may evidence the legal status of an employe(under the Worker's Compmsaiion Act. I understand that a copy of this ctal em nt may be forwarded to the Departnxat of Indsutriel Accidents'Office of Imuranoo for the coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties ooanisting of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a find of 3100.00 a day against me- ) For departmental uao only _ Permit Number �d A d444 rl% I/. ,/L/l/�.0 MaP# .Lot# • Si" •• of LiccnseelPermitice I -—CTION 8"°-CONSTRUCTION SERVICES o.1 Licensed Construction Supervisor: Not Applicable ❑ /�� /�S //J�lv1 Name of License Holder : Supervisor: � �� �W License Number Address O/30 Expiration to `-/??7 - <5- -O3 ?( Signatu / -le•. one / ` / /' # , - , 011, , Not Applicable ❑ Aler —77,1 :096 dr 6 Company Name • Registration Number. �ihV�j //e, /c/3 / Address 7 7 (177 �� Expiration Date Nf `� d 0:367 Telephone lo`� SECTION'1O-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MA I. 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. ;ned 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 V. ■ CT- 5,N 5 DESCRIPTION OF PROPOSED WORK(check:all applicable) New House 0 Addition ❑ Replacement Windows Alteration(s)❑ Roofin0 Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: aeld%/resitZ/44-1/AC eoc. c iGl� �A- , .e d. Alteration of existing bedroom Yes No Adding new bedroom Yes No e'lj° � ` Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 `7 ° : , ,` _i,! o- al :`: " i _. . :iJ «:,.soco i •t •• 40 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? .. 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 I, , 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 1 1, II •0,11ffitMilP e V r/Authorized Agent hereby •ecI-re that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the •a'• d penalties of perju . _....+,,,,e G - C=`r- . 1 I 0 Print Nam � 1 del q� AY • /rt9 Signature o :w•- 'gent Date �� Q • 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: ,- r l. . pt - 5-0 Q 10' �. ��a- x; A � A t r, .._ �..-.'m Ci 0 Northampton '� $ u'ildi ,g Department 2 ' •ain Street .• {;° R.om 100 �° ! 1 6,� :N rti- •. on, MA 01062 - , . . Q.. , 'a.. isfb fi 4 4harr6"'4 13-587-1240 Fax 413-587-1272 , Y2 _ . '' � ..-' ,,; fie—v3:;.: ,Sk;;;;;.r y.ki.. $ ':'zY` ; APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTI lN:1 SITE INFORMATION This sei s# h c dtom, ,itfl�1.1 Property Address: ! i � d `i` � E fi ` 9r rY 4 p l v e 4"e% / 4 AJI 14 p/64.,6 -,,,,,, -,,,,,,:;:-L.---•+:-4::,;:',': , ' - ;::-,, ,,,.%. ii 41 T�� Rim g ,.S;EETION: PROPERTY OWNERSHIPCAUTHORIZED AGENT 2.1 Owner of Record: ElP�46 Imo. f 1 .---7— c „.?......1 � .p/c J Name(Print) Current Mailing s: ©/6620 ' Mk ► + E!..;_�h Telephone CJ F-fr--7/..-- /?7, Signature 2.2 Authorized A.ail! r // .0_, e /e2d 'Z /9171 r //4 'I ' r �/ dp,e ,N , Current ngAddress: e 40 Olv3 Signatur= Telephone SECTION 3-- ESTIMATED CONSTRUCTION COSTS Item 4t/913—'----- Estimated Cost(Dollars)to be Official Use Only 1 completed by permit applicant FIV 1. Buil in: (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 ..tv . 6. Total = (1 + 2 + 3+4+5) Check Number This Section For Official Use Only Building-Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date, ( 4 41 CONZ ST BP-2001-0139 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 115 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofmg BUILDING PERMIT Permit# BP-2001-0139 Project# JS-2001-0212 Est.Cost: $1985.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: ROBERT D THIBODO 118441 Lot Size(sq.ft.): 15507.36 Owner: BART ELEANOR L&SUSAN E Zoning:URC Applicant: ROBERT D THIBODO AT: 41 CONZ ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-8966 NORTHAMPTONMA01061 ISSUED ON:8/8/00 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL RUBBER ROOF TO REAR PORCH POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings elk 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 8/8/00 0:00:00 7398 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo