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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L, Eii �C rG dC t 90-144 0
Gicens permlttee)
with a principal place of business/residence at:
Z/z `?cam e Cj s✓�>l� ��✓.��cco � (phone#)
(street/ci ty/statd2a p)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(In.,urrancc 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 workers 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) (ExTiration Date)
(attach additiaaal poet if mcuvey to inc} informatioa pertaining to all ooas rd s)
( ) I a n a sole proprietor and have no one wonting for me.
f I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowoera wbo alloy pc==to do main�=-Js�oo or repair work on a dwelling of
not more than thrto units in which the hon»owncr raider or oa the pounds aPV1d4aru1t lhwcto arc no(gc oa-2- y oomidercd to be
anploycra under the wmicces.mmpcnsatien Act(GL152-"1(5)),application by a homco%ma for a 6=3,-oc Parma may evideocc the
legal eta of an 0mV10yec undertho Workoet C.ompomation AcL
I uad=Tt=d dud a copy of this rEaiemeuL may be forwordnd to tho Department of Indu ,Ll Aocideai> Of$oe of Imuranoa for dw
Coverage verMcatioa and 'ire to Covaago under ration 25A of MOIL 152 can Icad to the iurPosition of crim:a Pen ':;s
000sutiag of a fine'oft Co S 500.00 imPzisoama4 of up to ono year and civil pantos in the form of a Stop Work Order and a
faro
o(5100.00 a rjay f ma
For dgrsrtlr�uao only
Permit Number Lot
gnahtre of LicenseeMermitlee e
SEGTb1 �O�IS7RUCTiJVERVICES� ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Resr s e e m pr me ont �Gii�r . Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION,,10 zWORKERS"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 affidz
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)familie
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 2(Worker$' mpensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in De�tli} the Mas c setts General Laws Annotated,you may be liable for person(
you hire to perform work for you unde, ''his ermit.
The undersigned"homeowner"certftes a assume ponsibility, r compliance with the State Building Code,City of
Northampton Ordinances, Stat,,,AAd L 1 Z sand Stag/` Massachusetts General Laws Annotated.
LI-Xomeowner Signature
�SECTIOIV CF21P C `> P OPOSED�WORK 'C e k a-1 llai6de , X33
`f."xm,gy�.,cmi sGaF3.Ra+�ry.h9flai3 .aa'yN fWN nP��l4 Y,4.„xupx` A'Y;VxA�mPNu'NA1,131� „ ,H :§yin n,n�i '++:s A F �i.Aj3 ���<
.:ik.a:; .ft�wz:.
"-9�” �9 ..VaJ][d[,ro....,:...0 e��.W=�.is �,���'�+�.Ih.�.°-. ..�u .,x :�a�.�'�i�sh�',A 1,. ,aY�.; :" 1,:�'..3,... 2- ,. ....•
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other[ ]
Brief Description of Proposed Work: L U' C +� `I��t �✓
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
6� If.Neui' ho�se�andor�iddi#"i�n�to"ezis#;Ing4housing complete #tie;fo141.owin�:
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
SECTION 7a OWNERAUT#IORIZATtON TO'BE COMPEEfiED VYFifI
OWNERS AGENT_OR,CO,NTRACTOR A'PI:IES FOR'$1111 DING.PERMIT
l 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
as Owner/Authorized Agent
hereby declare that the tements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.,
Signed under"the p ' sand pe Iti of perjur
Print, me
r`t t f
AJ 1
gna re /A 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:
� A
r
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 its
phone 413-587.1240 Fax 413-587-1272 0 .:ite
r Sp�o
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION1-SITE.INFORMATION
This sec#iort to be completed by of �Ce
Xl Property Address:
f' .0/a /J ' 6V lC Map
-Zone Overlay istrtc#
(�
V ,
Elm St. District CB;District'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: °
Name mt Current M fling Address: ?
Vi Y-73:3�i
Telephone �(r'(3L(I
ignat re
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECt10N,3 - EStTiMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
om leted
by ermit applicant
1. Building CJU (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 Only
B,uilding<'Permif;Number: Date Issued:
3:
S�ignatt!re
�Buildj g Cor missloner�inspec$or oflBuildings Date_
to . ..
X212 IttsBROQX, ` BP-2002-0242
GIs#: COMMONWEALTH OF MASSACHUSETTS
n : " CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:vinyl siding BUILDING PERMIT
Permit# BP-2002-0242
Project# JS-2002-0370
Est.Cost: $250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 10410.84 Owner: HEREFORD BRICE
Zoning.URA Applicant. HEREFORD BRICE
AT: 212 ACREBROOK DR
Applicant Address: Phone: Insurance:
94 MAIN POLAND RD (413) 369-4046 O
CONWAYMA01341 ISSUED ON:81301010:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL V I NY SIDING
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.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/30/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo