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I'll%nirlit uil�hr�[ulr m„u�lmr,I all - It . • ' A � �;.� �� f 4 a it' s DEPARTAfENI' OF BUIL)rNG INSPECTIONS Main Street a Municipal Building V- 212 Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE A MI A.VIT with a principal place of business/residence at: /1/ (phone#) �,-')" ( city/stalclap) 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 additioad sheet if nooeauy to include mformst w pettu=ag to all eontradon) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NQT1::plea=be aware thzt whilo homoowD tz wbo employ papaw to do=&inj�constructioaor repair work oa a dvcWag of not more than throe units in which tb t homoowoor resides or oa the grounds appurteaeat ibwoto src not Frnorally oocaukrcd to be easployc"uDd4r the-Deicer's oomp=4oa Act(GL1523s 1(5)),application by a homoowna for a Gocwto or p-mil may evidence tho legsl etabss of sa omployet under the Worfcex's Compemation Ad I undcr R dhst a copy of this uatemmd m ty be f«w+uded to the D"rtmc of Io&satriai A=deaad Offioo of Iawfw-for the eovepage Ycrificatioa and that fadure to soctue oowmp under soetion 25A of M©L 152 can read to tha imposition of criminal pcaakies of a fine of up to S 1,500.00 nodfor of up to one year and civil pamwa in the form of it Stop WA Order and a flan of S 100.00 a day against Inc. AC For dsr cptr °aty ' Permit Number • pL Mao Lot K Signature of Liceasedpermittee P ' 8.1 Licensed Construction Su ems: Not Applicable U Name of License Holder: License Number y 1?fifea zk;b-o y Address Expiration Gate S Signature Telephone Not Applicable 0 Company Name Registration Number 14 AWL) ST- s- /$'- oy Address Expiration Date Telephone — S®FIt X31[Q21C1`fiS' Ai1Rl 5ATILN;11t+tSCIR/stNCE-JkFF1DAYlT(M.G.'L.6. 152,§2op 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...... 0 The current exemption for"homeowners"was extended to include Owner-occupied DwelljR& 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 helshe shall be responsible for all such work performed under the buildine 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 t f" h JaL3 � s s �Nu New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing )q Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs { ] Decks [ ] Siding[[ ] Other( ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll 0-Sheet d 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 i as Owner of the subject proper hereby authorize to act my behalf, in all matters relative to work authorized by-this building permit application. Signature of Owner Date 1, EDLOA090 T bc T-T— ilk 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 penalties of perjury. T (Ij e>ee-n- the 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. Ar there any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: r � <� buuaing uepartment 212 Main Street �� . Room 100 - '�' � Northampton, MA 01060 pltarie 4G�3,5$7.1240 fax 413587-1272 pE LIGATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING tI� .raNS SECTION 1-SITE INFO M 1.1 Property Address: ;\ -�r Y� � ` - SECTION 2-PROPERTY O.WNERSHiP/AUTHOR�ZEt�yAGENT 2.1 Owner of Record: 4a!� v Name(Print) Current Mailing Address: Telephone 529�-62o((�J Signature lv 2.2 Authorized Agent: Ebwa -r Caoe sen- av y were S-j- Name(Pri 0 Current Mailing Address: s5A-R9-(0571 Signature Telephone �IrCT1ON:3 ES1 tIVIA' rJ G'O '�t iTtiDN CASTS Item Estimated Cost(Dollars)to be „Official Userly completed by ermit applicant 1. Building (a) Building"Permit°Fe's° 2. Electrical (b) Estimated Total Gast of Construction from-..Q,- 3. Plumbing Building Permit Fed 4. Mechanical (HVAC) 5. f=ire Protection 6. Total =(1 + 2 + 3 +4 + 5) '7,50- 0 Check Number This Sect an Ff r Of>ii.cial Usexb.nl' Building Permit Number:-. Date issued:,:, S3patu re: , l#u�idingComm�sstwnei�Inspector,at itri Mite',,. 577 BURTS PIT RD BP-2002-1182 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-555 CITY OF NORTHAMPTON Lot: -001 t Buildinea Category: BUILDING PERMIT Permit# BP-2002-1182 Project# JS-2002-1893 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Ed Corbett Jr 116069 Lot Size(sq. ft.): 43995.60 Owner: LEBEAU ANDREA M&EDWARD R Zoning:URA Applicant: Ed Corbett Jr AT. 577 Bt.,1 PIT R Applicant Address: Phone: Insurance: 4 Reed Street (413) 584-6571 NORTHAMPTON MAO 1060 ISSUED ON:6127102 0:00:00 TO PERFORM THE FOLLOWING WORK:STR I P & S H I N G L E 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: Or 6'13'Da'411V THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPT UPON VIOL ON OF ANY OF ITS RULES AND REGULATIONS. "' Certificate of Occu anc �� Si nature• Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building 6/27/02 0:00:00 1639 1639 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo