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�'�++"�� DEPARTMENT OP BUILDING INSPECTIONS • _r4 f
. 212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSA'z'ION INSURANCE: AFFIDAVIT
I, 3 c.„,,,-;\1- has-\o;tJ ' , Has-\c::N:., % ,\R;')Q.c---S
(li ce-nsz-c/permi ttcc)
with a principal place of businesJresidence at:
33, C_,o\e_sv-\_esz,..sz)0..E .\per\ c_,,$ecQbone ) 411 7'8(,—Oq ( c--e'
(strrwt/ci ty/statrizi p)
do hereby certify, under the pains and penalises of perjury, that:
(-6am an employer providing the following workers compensanton coverage for my
employees worinng on this job:
\ i c-0.■ e,\.-A—t A...,nS • Cs2) • I c 4 - WI 9- --?\/ y- 19 -1-97 ` oo
(tnsusoia Cody) (Policy Nam ear) Expirat on Dan)
( ) I am a sole proprietor, general contractor or homeovrner (c-i cle one) and have hired
the contractors listed below who have the following worker's cnE:p=iion policies:
(t` a.__,of Coo'ra:u . Cc Coi.r.panyiPoIicy Nuab•ao) FL.?m do c)
(Nd.inC of Co[l'uu'.c;oi) (1 ';11riocc CoinpailyIPot_`,C' Nu1i'.t;'.:r) (C.\pur2Uon Dan)
(Name of Contr2etor) (?nnrnnc:: Company/Policy Nruntya) (Expiration Date)
(N<une of Contractor) (Insurance Company/Policy Num r) (Ezpif2don Date)
(-ttidt�c':{it:cca1 pct ifccc=i:y CO d'O ic:cccnitica p._-1t_,riu8 to.JJ ccc3ra<'_on)
( ) I an" a sole proprietor and have no one worEng for me.
( ) I am a home owner performing all the work myself.
•
Nara pi..be aca,e that whilo 6octico ro ra wbo employ pert-om to do ;e-lea:ec rcpaa work oo a dwelling of
not mean than Lhr•o units in which(Sc considered to be
homootvocr rc�«oa tbo�mtndt�ppurtcn_nl tbu-dn�2 ooc�a12y
employers ti.'kicr tba wockcem cocpu-.. iioa Ad(GL152ss 1(5)),application by a homrocvner fm-s lio=cc ct-permil may evidence the
legal et3t,of an co Ioyx under tho Woc+ccet Compccc itioo Act .
. I uactcrst*-ad that a copy althin 0.1anm1 may bo forwotded to tbo DcpotiaDmt of In.dn ctx al Acodo&0t5oo of lanu•oco for the
cowrie Yrrificalica and that failure to ccatrc co%rra.So under socrioa 25A of MOL 152 cart Ind to tbo'imposshoa 01-a6m1ns1 Pm-ill-3c' . ,.
comisIIUg g s..fnx'of up L(351...500.00 cndtor imprhoccocot oCup d avi1 per al'a io the form nix Stop Work.Ordcr.and a
•
. fino of 5100.0p'i<diy igainit me
Fos:dcp�ztm ?1 Clio ooty
Pctmit Number
3Cfa..._ _ :.. }
Sigiiahirc 6f 1 •,_-. _,..-,_-
.
J J K REALTY
35 CONZ STREET
NORTHAMPTON, MA 01060
TO WHOM IT MAY CONCERN:
WE HIRED W. MAREK
2000. THE BACK PORTION TO PUT A
RTION OF THE BUILDING HAD A ROOF ON O OUR BUILDING
W. MAREK& SON HAD A NEW ROOF PUT IN THE SPRING THE BUILDING. WILL NOT BE UT ON THIS SP RING OF
THERFORE E ABLE TO COMPLETE
THE ROOF WE ARE NOW THE ROOF
HIRING HARLOW BUILDERS TO PUT FRONT YOU RONT PORTION
THIS PORTION OF
JCrNr
. or.
...011,
•
+–
0twrnT
� �s
*Cr itp of Nar# atpton _ _a� ti`E
�/s`f� E -
e " ,BZcsencncctla�1j1 &
�'^ II'' c i I
,c;:› DEPAP. MEIJT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'y
WORRIER'S COMPENSATION {NSURANCE AFFID AVIT
I,
(li ccuscdpenni ttcc)
with a principal place of-business/residence at:
(phone ?)
(st r=Vci ty/staicrzi p)
do hereby certify, under the pens and penalties of perjury, that
( ) I am an employer providing the following worker's comoensanon coverage for my
employees worlang on tins job.
(Insuranc Coetrany) (PoLic: Number) — (E:pinion Data)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who h2ve the following worker's compensation policies:
(Name of Coat::ctrl (In urnncc ColnpanyIPouc, Nut h ) (i=-).pirnuon Date)
(Name of Contractor) (In -wancc Company Policy Ntlncrr) (Ex-nu-anon Date)
(Name of Contractor) (Insuranc Company/Policy Numbu) (Expiraon Date)
(Name of Contractor) (Insurance Company/Policy Numbs) (Expiration Datr)
(,,ouch ,ri-litioc.J c_)cct ifncccs,ry to incu&inform,lioa pvtainins to all ooan-ac'.o:-s)
( ) I am a sole proprietor and have no one working for me.
( ) I am.a borne owner performing all the work myself.
NOTE:plc Ix ntvzre.h.•,WC bOcncov, ,1 Nho,,,,ploy perwm to do[ ,rt-tr ^,2.51,x)a-It,,III,Fork cra,d,.rIlIF,of
on(rnocc t o throe hits in which the botnootwcr rcnidc oc co the(rounds apPurtcnsr1 tbcco arc cc c ,ably coeridtczi to be
employes undo the t.v—,Cet c n :s:1im Act(GU.52.3,3 I(5)),application by e bonacowiler far:ilex=or permit rnty evidence the
Icgzl nano of no.naployor under rho Woc4ol.Cocpomu;oa An
I u -d - nod thot a copy of thi,rrarorocat may bo for-worded to tbo Dcpn,teoca1 of 1ov1..,.'cirJ Acadcat(Of5oo of lr,ur+nco for tho
covmtgc vc iic iioo and Qua Eiltnt to soot=bovcryb-c under section 25A of MOT_152 can Irsd to the osition of mmicui pcooi1 n
coosi.umg of a floc of up to 5 1.500.00 and/oc imprition:malt of up to ooc year end civil pcaaluo in the form of n Stop Work Order'and a
rim of S100.00 a thy t tt me
For dcc. mrzoJ UK Only
Permit Number ._
u
Si�ZLure of Liccnscc/Pcrmiucc Date Ma P::_ Lot
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: c�S`\�, . � .�'� C-)S—c t'(0
License Number
G
Address Expiration Date
Signa re Telephone
� -�� to a� ri�� i i "l I€l 3 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.
Homeowner Signature
SECTJON 5- D SCRIPTJOJ+I sr PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 'L
Or Doors ❑
Accessory Bldg. ❑ DemolitionD New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: \' ®U(2-- EX tl,'%\-c■A{$C & ® CiVi\----.A- C") 4 4.C: \°, IliRs.,
Alteration of existing bedroom Yes v' No Adding new bedroom Yes No /
Attached Narrative❑ Renovating unfinished basement Yes J No
Plans Attached Roll ❑ - Sheet❑
,. .1f . i , .@::;, «;i.® '11'.;1'''''* °.. i;-*AbtTtlttvvOiripleteLtheJo : '
a. Use of building: One Family Two Family Other r- C7,,xh.11
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? 'NQ
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 Yes No. Is construction within 100 yr. floodplain Yes No
i. Is construction within 100
ft. of wetlands? es � Y
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building nd Zoning regulations? J Yes No
I. Septic Tank City Sewer Building
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
—1 `,--. , 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 p nalties of perjury.
c----*Print Name '! -7
Signature of Owner/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
r s 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 V 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:
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans '
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans:-
Other Specify
kmig
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
--s ( 'ta�Z �� Map Lot Unit
\\‘;;---cikrA,,tqcS,( \s`\
Zone Overlay District
Elm St. District_.,_ CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: c
—
Name(P 'nt) • Current Mailing Address:
Telephone �--� s---...
Signature
2.2 Authorized Agent: %\\* ,
c-i\ S oC\∎r=� � _
Name(Print) Current Mailing Address:
•�/�
S-<d C , c34-6S-
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) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
35 CONZ ST BP-2001-0317
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 116 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0317
Project# JS-2000-1506
Est.Cost:
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Harlow Builders 052460
Lot Size(sq. ft.): 15986.52 Owner: SANSOM FRANK T&
Zoning:URC Applicant: Harlow Builders
AT: 35 CONZ ST
Applicant Address: Phone: Insurance:
336 COLES MEADOW RD (413) 586-0465
Workers Compensation
NORTHAMPTONMA01060 ISSUED ON:9/26/00 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP, INSTALL PLY & SHINGLE ROOF FRONT
PORTION
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: 0 dC /g..1 q D QiGfih
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu•anc %J''-• si.nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/26/00 0:00:00 4385 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo