The URL can be used to link to this page

32C-146 (5) 4)5 � :2 APR 2 g 2000 JJ DEPT Py c t k 16 r I -S s f o pX i, l 0 Q`1 t iAjLf pT0 of wart 11ailt}rfoil IN ' a � �iSa RChIt5C11a — DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT 4 4 (li censec/permittee) with a principal pl ce of business/residence at: / A / ( (phone#) V (stmt/city/stairJap) r�� do hereby certify, under the pains and penalties of peT'Iry, that: ( ) I am an employer providing the following worker`s compensation coverage for my employees working on this job: (Insurance Compan)') —(Police 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 Cornpany/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comrany/Poki ,Number) (Expiration Date) (Name of Contractor) (Insurance Company/Polict Number) (Expiration Dale) (Name of Contractor) (Insurance Compzny/PcEcy Number) (E)piration Date) (attach additiocal slice if nvcr y to inchsdc informshon patnirtnr to all n 2rndors) '`� ' nti am a sole proprietor and have no one working for me. /( ) am a home owner performing all the work myself. NOTE:please be aware that while homcowncra who employ pczonr to do m ,x�constuctioU or repair work on a dwelling of not Moro than throe Units in winch the homoowacr restidcs or oa the ground5 rppurtcaarrt thereto arc no(generally o..d.-rd to be employee Under the wm+- i comp=s4on Ad(GL152,Ts 1(5)�aMlicaflon by a homeowner for a liccosc a pcsnzd may cvi&nc"the legal lotus of an employer under tin Workzeg ConVeu ion AeL P� I understand that a oc py of this rtatemeat may bo forwarded to rho Dcpartmm¢of rndirsi d A=dm&Odoo of Iau"Ltoa for do cove zx verificafion and that failure to&come coverage under scctioa 25 A of MGL 152 can iced to the inxpos¢ioa of mmtnal penalties oomisting of a&ne of up to S 1 or of up to one year and civil penalties in do form of a stop Work Order'and a find of S 100.00 i day tnc For oalY Permit Number Lot 1gnat1II'e of Li rm-iU–ce ECTION 8-CONSTRUCTION SERVICES ALicensed Construction Su ervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date gna re / Telephone Not Applicable ❑ t v 12 6� 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. Al igned 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 Local ping Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 0 ,CTION 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: ?OMr✓+ 26�NO VAIN 0tJ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ y gomoleteAhwhllo 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? 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 MW,, 'CL as Owner of the subject property hereby authorize to act on my behalf, in all matter relativ o work authorized by this building permit application. lb fl0 Signature of Owne Date I 1 l AM—A–Tr� -P 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. Print Name Signatur of Own / ent Date T � 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 (0."100 SQ, I Frontage Z O Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage 1224 % Open Space Footage % (Lot area minus bldg&paved 5 l 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 y s, it 7 /�, `Room 100 ' Noampton, MA 01060 `q �°�r.... pgl -587-1240 Fax 413.587-1272 FAG APPLICATIGN.TO'EdNSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This sect�oh to be corrfpleted-ibyvoff lee Map c -- Lot Unit, Znn 04 lay,°Distirict„ EIMSt.Elkts tt +CB.DIstrict SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: MAZFlk S, �Ati,�� ►mil L ` ame(Print) Current Mai ng Address: S 4 - Telephone 3ignatur 2.2 Authorized A ent: z Name(Print Current Mailin g Address: �' - - r �e S ature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building i �� (a) Building Permit Fee 2. Electrical v (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 SD This Section For Official Use Only Building Permit Number: fii f 5–& Date Issued: — Signature: Building Commissioner/Inspector of Buildings Date File#BP-2000-0950 APPLICANT/CONTACT PERSON JOSHUA STEBBINS ADDRESS/PHONE P O BOX 1011 (978)544-1928 PROPERTY LOCATION 17-19 MICHELMAN AVE MAP 32C PARCEL 146 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 56- w &56 Typeof Construction: PORCH RENOVATION-ADD 2ND FLR PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 060886 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD I ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Co *ssion Permit from CB Architectu e Committee s s zoo Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. IPM (.r> gy, S5 rte: � v�+w�'°'n"MTMih.�✓� v v � � A� r r 17-19 MICHELMAN AVE BP-2000-0950 GIs#: COMMONWEALTH OF MASSACHUSETTS Man:Block:32C- 146 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:alteration-addition BUILDING PERMIT Permit# BP-2000-0950 Project# JS-2000-1741 Est.Cost:$3500.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor; License: Use Group: JOSHUA STEBBINS 060886 Lot Size(sq_ft.): 6403.32 Owner. EAGERMARPA Zoning:URC Applicant. JOSHUA STEBBINS MICHELMAN AVE Applicant Address; Phone: Insurance: P O BOX 1011 (978) 544-1928 WENDELLMA01379 ISSUED ON&/15100 0:00.- TO PERFORM THE FOLLOWING WORK.PORCH RENOVATION - ADD 2ND FLR PORCH 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: Douse# Foundation: Final: Final: Rough Frame: Gas Fire Deuortment Fireplace/Otimney: Rough: Oil: Insulation: Final; Smoke: _ Final• ' $►r3! .-Q 2 THIS PERMIT MAY BE REVOKED BY THE CITY F NORTHAMPTON UPON VIOLAT N OF ANY OF ITS RULES AND REGULATIONS7. Certificate of Occupancy si nature: . Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/15/00 0:00:00 506 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 I3�Iding Commissioner-Anthony Patillo