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'�W�� DEPARTMENT OP BUILDING INSPECTIONS * —
212 Main Street • Municipal Building . _
=
Northampton, Mass. 01060
n~ r'
WORKER'S COMPENSATION INSURANCE AFIADAVTT
, ...-
I, \G tit A./ C•,1_to e-
(Iicensec/permittee)
with a principal place of business/residence at:
•
SG (Jiinc.fie �` • LeeeLz /1412 DI o.C'i (Phone#) Jj- 8'>/01,_
(strcei/city/stateizip)
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)
•____ t neral contractor or homeowner (circle one) and have hired
the contractow� o who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
r
(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 additioaai short if neccisary to include information pertaining to all contractors)
( 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 persona to d>m 1,.tn,.R c WSrtrUdlOn or repair work on a dwelling of
not mote than throe units in which the homeowner raider or on the grounds appurtenant thereto art oat generally considered to be
employes under the worker's cengxazation Act(GL152,ss 1(5)),application by a homeowner for a 11=3's4 CC permit may evidcaec the
legal taws of an employer under the Wodcer's Compeosaiion Ad.
I understand that a copy of this statemmt may be forwarded to the Dopes-moms of Industrial Accidents'Olfioo of Insurance for the
coverage verification and that failure to secure coverage under section 25A of MC1L 152 can lead to the imposition of criminsl penalties
oonsitting 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
fum of 5100.00 a day against me.
For dgisttaxcial woo only
Permit Number
-
/1 I#___________Lot#
• . Si:..• • 0 icenseefpc ,,s tree uate
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
,i }/ °. e�� �vemen �. .ri �y
��,1):4'; ,, !V ; ., ' '' Not Applicable ❑
Company Name Registration Number
(J'►inn c>Iz S )
/l' /OR
Address Expiration Date
Telephone e 7/o1. 1>' j Q - 'L/
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
I
CTION �b .� PROPOSED:WORK c all applicable)
•
•
w c am ee sr
.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors fr
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: re fr Z01,Ct, (A);r, u/C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
allfINWAYOUre q, :tlditi:on.toez`isting tioirin' c`om"le'tethfoll'.a�in
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
SEC1I0074 OWERAUTKHORIZATION -TO BE COMPLETED' WHEN
OWNRpGN OR OOTRAT0R 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 _
ENV C;/? e , as Own: Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to t - •-
knowledge and belief.
Signed under the pains and penalties of perjury.
" ",AA, CrO ePfrr
Print Name
/1 • 9 6 0�
Signature of Owner Age Date
i/
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:
-eft' •` Northampton
Build' Department ' A
a in Street ®� �➢ � t
Room 100 a
��— —ar� rtamp
40 Fax on, MA 01060
rr �" �Zgef4�' 413 587 1272 P Sit M'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
3 i3 s tiLoon t to`� colete - y fi ce
1.1 Property Address: Ths ecr m /
Map
A V l C? ----Orl Zone �O erlay bistr�ct
/ 5��1�4z C
Elm St. District CB-District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: (�
/•-h Otte-/tn t'� 6-3 /Je-)-1'rd4,:e Ar(_" .SC',/rnoJC G.
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
r
OA .
c�2u�`_ S`,‹ i/t')a
Name(Prnt) Current Mailing Address:
/ 1
Ji S� —
Signat 4 Telephone
SEC % 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be I 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 G
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner%Inspector of Buildings Date
41 WRIGHT AVE BP-2003-0477
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 190 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0477
Project# JS-2003-0797
Est.Cost: $1085.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 6490.44 Owner: LORD RICHARD&VIOLET BRENNAN
Zoning: GB Applicant: John Corbett
AT: 41 WRIGHT AVE
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:11/7/02 0:00:00
TO PERFORM THE FOLLOWING WORK:I N STALL 4 REPLACEMENT WINDOWS
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/7/02 0:00:00 1466 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo