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29-327 (2) J• � e t 011iAM P�. �o oy Grit� Ulf 'Nart4 Iillpf a t + �las>sacfivactfa' DEPARTMENT OF BUILDr NG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licenseelpermittee} with a principal place of business/residence at: (phone#) (strevi/city/state/ap) 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 mpensation le one) and have hired the contractors listed below who have the folio os co policies: (Name of Con r) (insurance Company/Policy Numbcr) (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) (atlarh additional shoct ifnec==y to iae}ude infotmation pc tarmac to all ooatraGtOfS) ( ) 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 while homeowners who employ pasom to do Maiatmara,,cousiruetion or repair work on a dwcUiag of not more than three uaits in which the homeowner asides or on the ground3 appurtenant thereto are not generally considered to be employers under the vmcker's oomp=s4on Act(GL152,ss 1(5))�,application try a homeowner for a license or permit may evidcnoe the legal status of an employer under the Wmicda Compamation Act I undersisad that a copy of this riatcment may ba forwarded to tha Deputmc of Iodu*ial Aoadm&Offioe of lan"ooe for the coverage verifiedion and that failure:to sect=coverage under soctioa 25A of MGL 152 can lead to the iugrOSi ion of criminal penalties consisting of a fine of up to$1,500.00 andlor`impriuo of up to one year and civil pmatties in the form of a Stop Work Order and a find o(5100.00 a day a$ait s me For use only rj,, , A Permit Number p4 Lot# Signatxlre t of .,. 'cam w � r SECTION„8,-CPNSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ � 1 FINEW pP 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 Ordinan es, Latean WLoqca�zing Laws and State of Massachusett General Laws Annotated. Homeowner Signature r kIECTION 5 I li' ble New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ 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 o Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet o 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 I, 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 I, 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 n me nature of Owner/Agent Date silk" 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION:1-SITE INFORMATION 1.1 Property Address: 'sr hls �o�taEb 3omii?Y Qfflcf 5 E n i gEJl' t?tstrlct SECTION 2-;PR.'OPERTlf;,OWNERSHIP/AUTHORIIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: cLa Telephone _ nature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building d-� (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:Onl 1:3uilding Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 308 ACREBROOK DR BP-2001-0395 GIS#: COMMONWEALTH OF MASSACHUSETTS Map Block:29-327 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: woodstove BUILDING PERMIT Permit# BP-2001-0395 Project# JS-2001-0650 Est. Cost: $2000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Sizes . ft. : 10497.96 Owner: NAULT RONALD J&JUDITH A Zoning:URA Applicant: NAULT RONALD J & JUDITH A AT: 308 ACREBROOK DR Applicant Address: Phone: Insurance: 308 ACREBROOK DR (413) 585-8714-0 FLORENCEMA01 062 ISSUED ON.•10 113100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOOD PELLET STOVE 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:© K 6 a —/C- THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc �� Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/13/00 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo