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m DEPARTMENT OF BUILDfNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORI{ER'S COMPENSATION INSURANCE NFFD)A.VIT
(liceuserJpermittee}
with a principal place of businessJrresidence at:
Z\�S , _'x ` �`- ` O\c�S (phone#} ``�\3 2-���P��3
(str-eei/city/stalPJzi p)
do hereby certify, under the pains and penalties of pegury, that.
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
jas=can Company) (Policy Number) — —-- (Expiration Daze)
O I am a sole proprietor, general contractor or homeowner (circie one) and have hired
the contractors fisted below who have the following worker's compensation policies:
(Name of Contractor) Omsi=ce Com uyiPoky Number) (Expiration Date)
(Nine of Contractor) (lasurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insuraace Compaijy/Policy Numb(_,r) (Expiration Date)
(Name of Contractor) (Tnsttm c: ComDany/Policy NllmbU) (Z.xpiration Date)
(atia�: it±iti oc:il slid ifncccssssy to inc}udc infocrnstion p.:stnining to ell oocdractors)
(K} 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 homowAmcra who cmploy pczom to cio mniaj'a "cc:^, jc'icn or repair worst ou a dwelling of
not mote the taco Wu.in which the homcQwncr re=dc s or oa the grv,n appuitenanl tb_—eo tiL ryx Gcocraily ooasidcrcd to be
employrrs under tha worica's ccmpam4on Act(GL152,ss l(5)�appl ca ion by a hoewoRVa far n l ccux a pclm t may evidence the
legal rtntiis of an employoc under tho Wockces ConVwa&tion Act.
I undcrsttad that a copy of thin rwcmcui may bo forwarded to tbo Dc4nrtmcal of I.&u t i I A.&.&Offioo of Inert-for the
oov-_agc vrt-ification rind that failure to aerate covcrngo under scUioa 25A of MGL 152 can lead to the imposition of criminxi pen Wcs
coataing of a fine of up to 51,500.00 and/or imprizosmxut of up to one year and civil pen 16cs in the form of a Stop Work Ord—_and a
find of:3 100.00 a day s g&iwl mo_
For degsr Itsl use only
permit Number
Iviagl _Lot#
Signature of Licm-,cc- Permiace -
SECTION 8 .CONSTRUCTLON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
Z (ob
License Number
A22
Address Expiration Date
-�r, A:
Signature Telephone
V`R'.fs-ere" d i a mpr`u1ement Cgntra"ctor a, .u� ,.: _, ... Not Applicable ❑
�y Ct 4\ ',
Company Name Registration Number
Address Expiration Date
Telephone '`\�Zb3� �� A\ —2-
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....... lZ No...... ❑
iHome�Owner rExe pti n
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-vear 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 wort: 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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 14
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding X Other [ ]
Brief Description of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a' IfyNew�%liouse�and�or=atlilitton°„to exis"t�ng�:hour°ing,.;cottplete�the;followin�:
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
0 ER S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in m ers relative to work authorized by this building permit app icati n.
Signature of 94ner f Date
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
Signature of Owner/Agent 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:
T
4/
't f Northampton
2 di g Departmentu. Cuff
O 9 2�0 212 a i n Street S e Se d
R m 100 a v r.
pton, MA 01060 etso e .
-587-1240 Fax 413-587.1272 P�IolSlte K
OtherSpecify u
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to�be complQted by of fee
r r
L
Map
������� ►cam _ 7
Zone,, .Overlay Distr,�ct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: \ M�
Name(Print)! Current Mailing Aldress:
Telephone
Signature
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
_ completed by permit applicant
1. Building (a) Building Permit Fee
3 LCCU
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) c_c Check Number U a
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
e
XINGSLEY AVE BP-2002-0787
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 32C- 160 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:replacement windows/siding BUILDING PERMIT
Permit# BP-2002.0787
Project# JS-2002.1311
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KURT STAEB 127236
Lot Size(sq.ft.): 3005.64 Owner: MINTON JOSEPH E
Zoning.URC Applicant: KURT STAEB
AT. 5 KI NGSLEY AVE
Applicant Address: Phone: Insurance:
2115 BAPTIST HILL RD (413)283-6983
PALMERMA01069 ISSUED ON:3119102 0:00:00
TOPERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
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 3/19/02 0:00:00 3650 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo