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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFEDAVIT
&AA
(licensec/Permittee)
with a principal place of business/residence at:
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a.� C-CAAA. 1(CVt--k-7`f�C. �� Gt 4 �%f.0� (phone#)
(st e=Ucity/sta&2ip)
do hereby certify, under the pains and penalties of penury, 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)
e
( ) 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)
(anach additional sheet ifneceaary to iaclude infttmation pertaining to all ooatm o )
� a sole proprietor and have no one working for me.
P P $
( ) T am a home owner performing all the work myself.
NOTE:pl=w be aware that wbilo homeowners who employ person:to do ma�**+__c a_a_ was vaion or repair work on a dwelling of
not more thaw three units is which the homeowner resides ce on the grounds gTurteamt theedo arc not geaa'ally oonsidered to be
employers under the tvorkees oompensation Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal ctatua of an employer under the Worlrela Compamatioa AcL
I understand thst a copy of this ruatemect may be forwarded to tho Depwtmcad of Industrial A=Wa t e Offioo of Iasuaaoe for the
coverage verification and that failure to secure coverago under seW oa 25A of MGL 152 an lead to the'imposition of criminal penalties
oonsistiing of it fine of up to S 1,500.00 and/or imlais�of up to one ytar and civil penal$cs in the form of a Stop Wwk order and a
fino of 5100.00 a day against me.
For dgzatmr3al use Only
Permit Number
Map# Lot#
Sipab=of Lic6zee/Permittee
SECTION;8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not(A"p'�plicable/ ❑
Name of License Holder: `/
' I �' 7 L/ l I q
License Number
Address Ex'r ion Dat
4
ig ature Telephone
Not Applicable ❑
W
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1#I-WORK RS"COMPENSATION'INSURANCE AFFIDAVIT(M.G.L.c. 152,§2 C(S))
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.
1.1jigned 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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DAKDR09KIchack all e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: t�4 Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
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
ECTIO 4 7th �0WKEII AQTHORlZATlON -TO BE COMPLETED WHEN
BUt
# TO ONT�tAOT3IAPPLI51"OI Na PERMIT
as Owner of the subject property
hereby authorizeu `1�f 1 ' to act on
my behalf, in all matters relative to ork authorized by this building permit application.
�S c,
Signature of Owner Date
I-killk AcAftl 0 as Owner/Authorized Agent
hereby declare that the statements and informa ion on the foregoing application are true and accurate, to the best of my
knowledge and belief.
igned under the pains and penalties of jury.
b
Print Sae
Signature of wner/Ag nt 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 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 -.SITE"INFORMATION
1.1 Property Address: k '
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SEGTIl3N 2,-.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
3 4191ESTIM ATED CONSTRUCTION COST5
Item Estimated Cost(Dollars)to be 0 iciat Use Oniy,
completed bv Permit applicant
1. Building �0 �L� �� (a) Building Permit Fey
2. Electrical (b) Estimated Taal C-ost of
Construction frofh ,6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+ 5) Check Number
This Section F Official Use Only
Bonding Permit Number: Date Issued:
Sinature:
Building Commissioner/inspector of Buildings Date,
BP-2001-0851
GIs# COMMONWEALTH OF MASSACHUSETTS
owM CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2001-0851
Project# JS-2001-1588
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEITH HAMILTON 074129
Lot Size(sq. ft.): 6011 .28 Owner: ANDRUS BERNICE R&CAROLE A
Zoning.URC Applicant: ANDRUS BERNICE R & CAROLE A
AT: 31 KINGSLEY AVE
Applicant Address: Phone: Insurance:
31 KINGSLEY AVE
NORTHAMPTONMA01060 ISSUED ON:
TO PERFORM THE FOLLOWING WORK:N E W R 0 0 F
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. Y /�
Certificate of Occupancy Si nature:
Fee Type: Receipt No: Date Paid: Check No: mount:
/CoBuilding � 250 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo