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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, 739( 1 - S A) I--
(li permitter)
with a principal place of business/residence- at:
X/0.0- 1 lfA,1 i o� 1,M (phone#) d"d�'� ' L
(streeUCity/ ap)
do hereby certify, under the pains and penalties of pegury, that:
Kam an employer providing the following worker's compensation coverage for my
employees working on this job:
/3c-6T U;0,412-lvS LL c /-3/u'- 1721-0/O
ce 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 worker's compensation policies:
(Name of Contractor) (lnsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F-\piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional short ifn6ocuiry to include infocmuioa pertaining to all ecatr,'aors)
O 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 hcmcowvcn who cmplay p,som to do rn.i„t'n•nce oorssb-udioa or repair work on a d«t ling of
not more than three units in which the homcowvcr resides a oa the grounds appurtcaant thado arc not gc owr y oomid red to be
employers undo the workees compcm4on Act(GL152,s 1(5)),application by a homoowmr for a Berme a permit may evidence the
legal ctatas of an employer under the Workers Compenvtion Act
I undentsnd thzt a copy of this rtatemcnt may be forwarded to the DcVxi tr,3 t of L.LL h id Ac6dw&OfSoo of In-u-for the
coverage verification and that failure to socure ooverago under section 25A of MOL 152 can lead to the imposition of criminal penalties
oomiAing of a fine of up to S1,500.00 and/or imprisoamcai of up to one yzar and civil pcwi is in the form of a Stop Work Or&r and a
firm of S I00.00 a day against ma
Ermit use only
—'' Number
O z Lot#
Si gnature of LicenseelPe ttce DEiEe
w
SECTION 81wC ONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number`e
�2W.1 A/
Address CC // �/ Expiration Date
O� � G�', fir` P /V Q Y 74 A r,V T�
Signature Telephone 0 b J
9Regs ee me : p .e►nent. o�nractor „ 11im norm, Not Applicable ❑
Company Name y� Registration Number
Address �j Expiration Date
1 _
Cc1 Telephone 6 - C7
SECTION;10 WORKWR'!XO,MPENSATION INSURANCE AFFIDAVIT(M.G L. c. 152, §25'C(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 faun
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
SECTION"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:
Alteration of existing bedroom Yes No Adding new bedroom es No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
sa,=°If New tiouse�andOr'addition° o existin fousin
g g,"complete�tlie: o owfni7:
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?
In. 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
01WNERIS,AGENT ORtO" NTRACTOR APPLIES FOR BUILDING PERMIT
'2O ti A�� r� 0 as Owner of the subject property
hereby autho 'ze Elp,io,IJ L r2 /-A. to act on
my/behalf, i all matters re tiveM work authorized by this building permit application.
r0/ U a �
Signature of Owner Date _.
I, t,) L 10442 as Agent
hereby declare that the statements and informat" n on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
i T
Print Name
Signature of almar/Agewt Date
r
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:
!` r
City of NorthamptonS
Department Curb u D
�t .'Q12 Main Street Se r e =
i r – ------- ---- �i Room 100 Wa erlNe
J'' ,
i�-��T1240 q� pmpton, MA 01060 NOV �h€ Fax 413-5871272 Plo /Site, an :
� -
! Other�Speci
STR CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to b, completed by office;
Map Lot Unit
6/a E- C, 1/Y]e4 Zone Overlay District
E
Elm St. District CB Districf
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
11?6 sJ 'el U � �:i e� 6/ -'c
Nam (Pr Current Mailing Address-
. r/0
Telephone_
Signature (; 93 yy
2.2 Authorized Agent:
Name(Print) Current Mailing Addr ss:
S"Y G —
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building �y (a) Building Permit Fee
2. Elecirical (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
Building Permit Number: Date Issued: _
Signature:
Building Commissioner/Inspector of'Buildings Date
BP-2003-0506
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0506
Project# JS-2003-0839
Est. Cost: $2780.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: B & R Siding 100465
Lot Size(sg. ft.): 13590.72 Owner: BUSHEY RONALD J&LOUISA A
Zoning:URA Applicant: B & R Siding
AT: 40 AUSTIN CIR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:11 115102 0:00:00
TO PERFORM THE FOLLOWING WORK:I NSTALL SI DI NG ON GARAGE
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 11/15/02 0:00:00 18528 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo