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12C-110 4--�1tAMP�p �O o 9 B �assarhnsrtta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building , o Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT with a/�prin sin cipal place of buessJresidence at: `2 j 4.40-ut)>2•- /� L.�.G'�° 01645.3 (Phone#) 4/(.3-fd y Jn?VP� st�i/city/stat�J�p) 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: (lnsu_ cn Company) (Policy Number) (Expiration Date) (%I'/I am a ole proprietor eneral contractor or homeowner (circle one) and have hired the contracto ow who have the following worker's compensation policies: (Name of Contractor) (Insurance Compauy/Policy Number) (E)piration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/pohcy Number) (F—\piration Date) (Name of Contractor) (Insurance Cotapany/Policy Number) (Expiration Date) (attach additional shce if no:css to ine}udc iafonnaIIon pertaiaing to all ooatmdors) i ( am a sole proprietor and have no one W' O iLng for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that vibAc homco"ncra who crW Icy pons to do majatcrLxncc cor3truc.ioa or rcpair work on a dwclliag of not more than throe units in Kfrich the homeowvcr resides or oa the grounds appurtenant tbcceto arc no(generally ooesidcrcd to be employers under the worker's oomp<zmatioa Act(GL152,ss 1(5)),application by a homco"ma for a l cawc or perms may cvidenoe the ltga!&tams of an omployor under tho Wockxet Compemation Ac(. I uadcntaad that a copy of this aYat—mf may bo forwardod to tho pcpartarnf of Iod=unial Aocid-&Oflioe of Iuwrwoo for the oovcsage verification and that failure to soatre covernV usdcr section 25A of MGL 152 can lead to the imposition of cnmi>ul pcnaWcs ooauxtmg of a fine of up to S 1.500.00 and/or imprisoaaxrlt of up to one year and civil penalti a in the form of a stop Work Ord--and a fum of 5100.00 a day a&nitui tr Fors!use only permit Number /c�•.�/•s ti Map's Lot# „ of Licenseelpermi' e SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction TSSurvisor: Not Applicable ❑ Name of License Holder : ?h kP4 e3 /3 License Number 7/ ettt.�') AIR -7 Address Expiration Date v �-- ,3 .�,� z Si re Telephone F.n- 9.:Re i sf"re" Homy-Im vemen on rac r � .� � �HFa w.ti „a, ,,,_ Not Applicable ❑ JS G r 77 Company N me Registration Number A -'? - -z GG 8-,Y• Z�**y Address J Expiration Date ( ;?141'relijk/ /vim/ 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...... ❑ 11:%- ome r.caner Eemph 'n 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 f s, SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: ZK11WU Ua J in Q,r•v © cl " Alteration of existing bedroom Yes_ ,-' No Adding new bedroom Yes ✓No Attached Narrative❑ Renovating unfinished basement Yes -/No Plans Attached Roll ❑ - Sheet❑ sa"If,NeWShdilit—a01:e-.`addition to ezi§tin? hdusinJZ, comp1et6Ahe"f6l1,6wi`ni7: 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 SECTION 7a-OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ejrr C ar ni d i TA So I4 as Owner of the subject property hereby authorize /C C hn-leA L o CL A Z to act on my behalf, in all matters relative to work authorize by this ildi g permit application. l0 ._ y Signature of Owner Date '.2' ceg C as Qwmer/Authorized Agent hereby declare that the statements a d information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under he pains and penaltie of perjury. Print Name Sig re of Qwwr/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 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 :Z 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: City of Northampton Stat�St0 Per, Building Department Curb Cu U 212 Main Street Sew KISeo a Room 100 a e lWeli�A , 1t . Northampton, MA 01060 TwoSeso r ra a phone 413-587.1240 Fax 413-587-1272 P►otlSlte P � Other Sperrify.� h APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office r Map Lot-, Unit b Z— Zone Overlay District Elm 5t. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /'-61- r / c / t'- G 4 ( xy-f.x '- 'r t9 I .`Gz' i . . !`7oI'CNDa z1e-J Name(Print) 17 Current Mailing Address: p ,g (a — 363 Telephone Signature ,,rp,�,� s04* 2.2 Authorized A ent: y r sti P 6, lF'a�o �/4�0' ��- .✓ 6J�S'3 Na (Pr' t) Current Mailing Address: Si re Telephone SECTION 3 -.'.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building -P �� (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 lssued: Signature: Building Commissioner/Inspector of Buildings Date 69 RICK DR BP-20030455 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 12C- 110 CITY OF NORTHAMPTON Lot:-001 Permit: Building Cate BUILDING PERMIT Permit# BP-2003-0455 Project# JS-2003-0770 Est.Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KENNETH LYNDS Lot Size(sq. ft.): 10497.96 Owner: SOTO HECTOR L& Zoning_URA Applicant: KENNETH LY N D S AT. 69 RICK DR Applicant Address: Phone: Insurance: P O BOX 448 (413) 584-9282 LEEDSMA01053 ISSUED ON:11 14102 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 Sisnature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 11/4/02 0:00:00 2299 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo