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29-349 (3) N �O I �r t? Grit if &Narf4aiiipf n _ 9 6aisachttsrtta' zfl DEPARTMENT OF BUII.DDIG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMTENSATION INSURANCE AFFIDAVIT (lic,�permittee) with a principal place of businessfresidence at: (phone#) (streeilci ty/statr/zi p) do hereby certify, under the pains and penalties of perjury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insu mne Company) (Policy Number) (Expiration Daze) ( ) 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 Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/poky Number) (Fxpiratioa Daze) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (atlach additional shcet if nocc- y to include information pertaining to all ooetradon) O I am a sole proprietor and have no one working for me. am a home owner performing all the work myself. NOTE:please be await that whilo homcowvetz who cmploy pcsons to do m•�coustuctioa cr rcpair work on a dwclling of not mote than tlxce unit,in wfncil the homeowner resides or on tht grounds appurtenant thado arc not gcocrally oxnukrcd to be employto undo the wmicc .compCasatloa Act(GL152,s3 l(5)�application by a homcow=for a 6-st or pumit may evident the legal ctatua of an employer under tho Worka'e Compensation AcL I undcru,tnd that a copy of this cWcmcat may bo forwarded to tho Dcpertmccd of Industrial Accideof Offioe of lastu not for tho covcmx vailication and that failure to aeaue covcrngo undcr section 25A of MOL 152 can lead to tbt iatpOSition of tximi W penawes oomistia of a fine of up to S 1,500.00 and/or i mpriso of up to oat ytar and civil pcsnitia in d)c form of a Stop Work Ord=and a fine of s 100.00 a day ag�tinA me. For dcput�uao only permit Number pii Lot 4 ignat=of Liccusee/Permittee e 4 w SECTION'$ CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone � f, Not Applicable ❑is Mx1 �M m ± Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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...... ❑ ame 'OwnW4Exempt 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 /' SECTION 51DESCR�PTIONtOF PROPOSED WORK(check3 all applicable) ar �vTf ?- ....: 3... New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ � Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[x] Other [ ] Brief Description of Proposed Work: 71er-ou ~ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ If New douse aril or additiori'to�eitisting housing; complete th&Jb11owihk: a. Use of building : One Family _ Two Family--Other b. Number of rooms in each family unit: 5 Number of Bathrooms_ c. Is there a garage attached? �\)0 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 . f. Septic Tank City Sewer Private well City water Supply SECTION i7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES;FOR BUILDING PERMIT as Owner of the su.;bject property hereby authorize to act on 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 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 N e Signature f Owner/Agent 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 a Building Department Lot Siz Fronta Setbac s ront Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved arkin ) #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 X IF YES, has a permit been or need to be obtained from the Conservation Commission? f\)('y Needs to be obtained Obtained Date Issued: C. Do any signs exist on the property? YES NO X 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 X e phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: Th s secti,4 to b:e'"com'pleteda office Map Lat "' 1nrt Zone s �� 0v rlay Distr' � � � x �; �3� °�- a '-vim. Elm St°District` CB Dis�rlct " SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print Current Mailing Address- Telephone Signa ure 2.2 Lthorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only com feted 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) f Check Number This Section'For Official Use Only' Building"Permit,Number'.. - Date Issued: Signature: Budding;Corrimissione►/Inspectorof Buildings," i ie I j { f l d r- r 56 AUSTIN CIR '' BP-2001-1104 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-1349-., CITY OF NORTHAMPTON Lot:-001 Permit:' Building Category;vinyl siding BUILDING PERMIT Permit# _BP-2001-1104 lwject# JS-2001-1942 Est.Cost:$3000.00 Pee: 2 oo PERMIS.SIONIS HEREBY GRANTED TO:; CMA Class: Contractor: License: Use Group: Lot Si sq. Q: 14157.00 Owner: WORSNOP LON R&DIANNE S Zoning:URA Applicant: WORSNOP LON R & DIANNE S AT: 56 AUSTIN CIR AoyficantAddress: Phone: Insurance 56 AUSTIN CIR FLORENCEMA01062, ISSUED ON.-&261010 Q0:00 TO PERFORM THE FOLLOWING WORK.-REMOVE & INSTALL NEW 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: Roughs Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: 4i1: Insulation: Final: Smoke: 1+'inaY. THIS PERMIT MAY BE REVOKED BY THE CITY OF N THAMPTON UPON VIOLAMO OF ANY OF ITS RULES AND REGULATIONS _ G. -00�w " icate of Orgugancy signature:,,, Receipt No: Date Paid: G` I No: Amounts Building 6/26/010:00:00 626 $25.00 n 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo