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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 'V
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensecJpermittee}
with a principal place of business/residence at:
(phone#)
(street city/statrhip)
do hereby certify, under the pains and penalties of penury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance 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) (Insurance Company/Policy Number) (Expiration Date)
If I..
(Name of Contractor) (Insurance Compauy/Policy Number] (Expiration Date)
(Name of Contractor) (Insurance Compa y/PoUcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach ad&tioml shod if noocsauy to include information pertaining to ell ooahm n)
( ) I am a sole proprietor and have no one working for me.
(�f I am a home owner performing all the work myself.
/ 'NOTE:please be aware thai while homeowoeta who eruplay persons to do maintenance,coast i=oa or repair work an a dwelling of
not moee than throe units in which the bonteowncr resides or oa the grounds appurtenant therdo ate not gcows.4 comidercd to be
employers under the worker's oompeasaticn Act(GL152,ss I(5)),application by a homeowner for a licewe or permit may evidence the
legal status of an employer under the Worker's Compomation Ant.
I understand that a copy of thin etaicmad may be forwarded to tho Dcputmccd of Industrial Accidw&Offioe of Insurance for the
oovcsxge vrsificatioa and that failure to seatro coverage under section 25A of MOL 152 can lead to the imposition of criminal pcna ies
ooasisting of a fine of up to 11,500.00 and/or imprison of up to orx year and civil pcml es in the form of a Stop Work Order and a
firm of 5100.00 a day agaitsst m t
For dqurtmoaW use oat/'
Permit Number
Map# Lot#
Si of Licensee/Permittee L�ie
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑t.,t... »....���� ��.."'
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.
Signed Affidavit Attached Yes....... ❑ No...... ❑
3 rd\
fi
On
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 "o�/ CAI�
• ft �
SECT O all applicabl e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitiony New Signs [ ] Decks Pq Siding[ ] Other [ ]
Brief Description of Proposed Work: i-e 1wil 47ft4-E- F-w—ck 5Cl4w
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
t
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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 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
1, tl..,z J/ .t f An
Signa ure f Owner/Agent bate
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
ME 111:kPiNjilill
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This section pmpl ted lY ffl
Map x � tnrt�
11e O 4
EI St.-Dlsti s wlctM
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: O(od
.'-vy-31`fs�
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATEQCONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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) 4- Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
�. 40,v
File#BP-2001-0228
APPLICANT/CONTACT PERSON C RMIEN MARK
ADDRESS/PHONE 13 LEXINGTON VE (413)584-3145 Q
PROPERTY LOCATION 13 LEXING ON AVE
MAP 30A PARCEL 042 ZONE URB
THI SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: T)IfmnLISH&REBUILD EXISTING FRONT PORCH SAME FOOTPRINT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory.Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS B EN TAKEN ON THIS APPLICATION:
Approved as presentedibased on nformation presented.
Denied as presented:
Special Permit and/or S to Plan Required under: §
PLANNING BOARD ZONING BOARD
Received& ecorded at Registry of Deeds Proof Enclosed
Finding Required unde : § w/ZONING BOARD OF APPEALS
Received&R corded at Registry of Deeds Proof Enclosed
Variance Required and r: § w/ZONING BOARD OF APPEALS
Received&R corded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Boar of Health Well Water Potability Board of Health
Permit from Consery tion Commission Permit from CB Architecture Committee
SiMiature of Buil g Official'/' Date
Note: Issuance of a Zoning permit oes not relieve a applicant's burden to comply with all zoning
requirements and obtain all requi ed permits from Board of Health,Conservation Commission,Department
of public works and other applica le permit granting authorities.
4,..w- . A,
13 LEXINGTON AVE BP-2001-0228
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block: 30A-042 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2001-0228
Project# JS-2001-0378
Est.Cost: $3000.00
Fee: $50.00 ERMISSIONIS HEREBY GRANTED TO:
Const.Class: C ntractor: License:
Use Grou._p:
Lot Size(sq.ft.): 6316.20 O ner: CARMIEN MARK
Zoning-:URB A licant. CARMIEN MARK
At. 13 LEXINGTON AVE
Applicant Address: Phone: Insurance:
13 LEXINGTON AVE 413 584-3145
FLORENCEMA01062 I UED ON.8129100 0:00:00
TO PERFORM THE FOLL WING WORK.-DEMOLISH & REBUILD EXISTING FRONT
PORCH (SAME FOOTPRINT)
POST THIS CARD SO IT IS VIS BLE 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 De art ent Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVO D BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG LATIONS.
Certificate of Occupancy S; nature:
Fee Type: Recei t o: Date Paid: Check No: Amount:
Building 8/29/00 0:00:00 1217 $50.00
212 ain Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo