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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFI+IDAVTT
dice 1pminittce)
with a principal place of business/residence at:
A (phone#)T ` c
(street city/sta diip)
do hereby certify, under the pains and penalties of perJtuy, that.
( am an employer providing the following worker's compensation coverage for my
employees working on this job-
AA� a-Q._._.
(I ncttrance 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 Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/policy Number) (ExpLmdon Date)
(Name of Contractor) (Insurance Company/Policy dumber) (Expiration Date)
(atIach-kbtioal&!cc tfnoce == to mctudc infrxmaiioa pertaining to all ooatm on)
O 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 whilo homcownm who employ pasam to do Mx oanjtr ioa or repair work on a dwelling of
not morn than three units in tvbiclt the homaowncr r=des or oa the grounds appurtenant therd art no(&cacra.1ty coasidcmd to be
employers under the wurkcts co- s Cn Act(GL152,ss1(5)�application by n homeowner for a L,0=e or permit may cvidmoc the
legal status of an omployec under tho Workoet Compemation AcL
I undcratand that a copy of tbv ctattmcUt may be forwarded to tho Dcpartaaid of Iodzutrial A e6d=&Oflioe of In�for the
coverage verification and that failure to secure coverage under sec6oa 25A of MGL 152 can lad to tba imposi ion of criminal penalties
ooasistirtg of a fine of UP to S1,500-00 aallor imprison of up to one year and civa pcnattia in the form of a stop Work Ordtr and a
find of 5100.00 a day against mc_
Foe dgmt'dal ur o ocay
Permit Number
T&1A Lot#
Sig mb=of Liccnsec/permitiee e
SECTOS� C "NS
ell
UTiO�I SER1lICES
7q
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
dam: m rremen n r 'r fir,r Not Applicable ❑
Cr
P60 A& 3
Co any Nanid R gistration 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 affidz
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No......
() W
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie
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(
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
SEC7?ION D SC P-TFlONtOFJPRQRO SED DIY =eh"ck al"--abb Iicable "
'�.s'I, ^
... P �e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: � �ffl
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a 1f NeW. 6us'e �ntl or addition tie lstirtg h0 is=ing;complete the follow,rn :
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
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
S;E,CTION 7a OWNER AUTHORIZATION TO,BE°Cl)MPLETED WHEN
OVYNERS AGENT''.OR CQNTI2AGT,OR APPLIES FOR^g3ClDING PERMIT
as Owner of the subject prope
r
hereby authorize } f to ac
my be n all ry6kters rela e to r authorized by this building permit application.
s'
re of 0 er Date
a1Dwzw;/Authorized Agent
he eby declare statements a d information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Nam
4 , E
Signature of caner A Date
w
c
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,Po-; it/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 #
I
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,thefe any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
City of Northampton
Building Department
R
212 Main Street
Room 100
Northampton, MA 01060 °
phone 413-587.1240 Fax 413-587.1272 a e
r
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION - SITE INFORMATION
This section to be completedj office
1.1 Property Address: � � 7
Map rL�ot
Zone Overlay District '
T
Elm St. District, CB-District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 r of Rec d:
AS
N (Print) Current Mailing Address:
�/ Telephone
Signature
2.2 Authorized Agent:
F- �"� d G /117 `Z
Na Current Mail(in�Add/Tess: '
Signature ITelepho ne
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost(Dollars) to 6e Official Use Only '
completed by ermit 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 Comm issionerAnspector of Buildings Date ,
9,PROSi') CTST '. ;{. BP-2002-0575
GIS#: COMMONWEALTH OF MASSACHUSETTS
t ak:24D 004 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2002-0575
Project# JS-2002-0896
Est. Cost: $5300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin HAWKI NS ROOFING 113957
Lot Size(sq. ft.): 6621.12 Owner: MILLER DUSTY&PATRICIA WIELAND
Zoning:URB Applicant: HAWKI NS ROOFING
AT: 229 PROSPECT ST
Applicant Address: Phone: Insurance:
P O BOX 107 (413) 774-6834 Workers
Compensation
GREEN FIELDMAO1302 ISSUED ON:12/11/01 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 Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/11/010:00:00 10395 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo