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m DEPARTMENT OP BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE A- FU)AVIT
(licelise�/permitter) --
with a principal place of business/residence at-.
7 1pTZn.! (phone#) 5 2 c/—oi�e1
(btreeilcity/stat&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:
(Insurance Company) (Polio Number) (Expiration Date)
T am a sole propr" tor, geaeral contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's celnpensation pciicies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (l.nsurance Company/PoLicy Number) (ExTp ration Date)
(Name of Contractor) (Insurance Compauy/PoEcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anaclr a.dditioml shte ifnoecisary to include infbnnxt cn pertaining to all Goat scion)
(�I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plc=be awarc that whilo homcovvcrz who ccwl oy pcnoar to do m.;n�mnstructioo cr rcparr work oo a dwclhng of
not mote than throo units in which the homoowncr r=dcs or oa the grounds appurtenant tberdo arc oo(grocrally eo¢siticmd to bt
employrr9 Undo tha worictt's ccaT<=seruoa Act(GL152-"1(5)),application by n hotncowncr far a Borax oc permit may-id-cc the
legal status of an omployor under the Workods Compomation AcL
I understand d>st a copy of this rEatcmcnt may bo foewnrdzd to t1x Dcpartaxut of Inds, i l Accidmi3 OfSoo of Lanxwn a for tb*
coverage verification and that failure to sccurc coverago under scctioa 25A of MGL 152 can Icad to the imposition of aimirw pcnaltics
oomisting of a fine of up to S1,500.00 andloc imprisonmait of up to coo year and civil pmsltics in the form of a Stop Work Order and a
fino o(5100.00 a day against me.
For dcpa�use only
Permit Number
WI
—?12� LA Lot#
J
signature of Li ermittce BeEe
x
SECTION'.8 CO,NSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : `�e/' � � :?,o
License Number
C72
Address Expiration Date
Signature Telephone
_`y!W- Not Applicable ❑
Reg(STeretl�F "ome Improvement'Conactor. �' ��, ._
I
Company Name Registration Number Pt
Address _ Expiration Date
Telephone���c��07 �
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...... ❑
�p: 7
11. w H.a rlempta<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 5 DESCRIPTIONYOFiPROPOSED 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: i� � Z �`� TG"
i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes _No
Plans Attached Roll ❑ - Sheet 0
6a; If New House anci or..:additio'n to ezis'ting h`o"'using, complete`,lithe,followih :
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
I
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves_ Number of each
g. Energy Conservation Compliance. Ma-scheck Energy Compliance form attached?
i
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 -OW NER,AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize 1J �i /� l'� ' � to act on
my beh f;In all matters relative to work authorized by this building permit application.
c
Signature of Owner Date
6� 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.
D&WW1*t1)
Print Name
e O-Z
Signature of Owner/ en 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:
r
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City of Northampton
a ilding Department
c V 12 Main Street e e
Room 100
`i ampton, MA 01060 T at
pf��'ffR st�f c r
iljN 14 nn,,
4 ' -5 7-1240 Fax 413.587-1272 PlotlSlte�Pfas � _ :
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___T4JCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office g
AM
s
Map Lot U fk '
p Zone Overlay District 9
Elm St. District` CB District'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
r
i r 1)uvA�- --- , Six' K6
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
0102-7)
Name(Print) Current Mailing Address:
Xt't y- , C7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building I 12 (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
Building Permit Number: Date Issued:
Signature: .
Building Commissioner/Inspector of Buildings Date
BP-2002-1124
G1S#: COMMONWEALTH OF MASSACHUSETTS
C OWN-
Lot: k CITY OF NORTHAMPTON
-001
Permit: BuiIdinl7
Category BUILDING PERMIT
Permit# BP-2002.1124
Project# JS-2002-1800
Est. Cost: $1512.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 32582.88 Owner: DUVAL PAUL H TRUSTEE
Zoning:URC Applicant: DE Sheppard Roofing
AT. 94 HAWLEY ST
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTON MAO 1027 ISSUED ON:6117102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & S H I N G L E ROOF
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 6/17/02 0:00:00 527 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo