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DEPART1,ENT OF BUILDING INSPECT-10,\'S
212 Rain Street ' Municipal B1111tlirtg '
Nor thamptoil, Mass. 01060
WORKER'S COM-PENSATION INSURANCE AFFIDAVIT
I,
(li ccn_scdF�.,mlucc}
%vII 1 a principal place of busiresshesidence at:
DEVb�
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Cl0 11CiCby` CCi"t1iv, 11n:'CI ills i ,?iits and p(:i131i1CS of—, IlllY, (Ilia:
I ani all empWyer providing the iollo5vim] .roi"k&S compcns�l III
eltlplovecs working on Leis lob.
(Insuuancz� Company) - (Polk' Number) - — - -(Expiration Datc)
{ ) I asn a sole prounctor, "(eneral contractor oc houleowner (circle One) <:nd 11aVe hired
the cont'Tactors 13Sted beiov',,ii'ho hat.'e the fQ O:v n% �VOr e�S (:J[i i)'CrIS?aOi) t)�iiC:GS-
(NIP_r11e OI Co ltrlcto�) 'Rnsu :nc: CoIlmanyrTobicy Nusnt,,r) (I.>:[".rc tion DatC)
(Nainc Of COCIr2Cioi) (Ins-UT-ancz Conloaav/pd1c)' Nunik-l"
(2'tame of Contractor) (Insura3lc� CompauyiPolicy Ntu3ltxr) 1?ate)
(Name of Contractor) (Insluanct� Comp,:ny/Pohcy Numb r) t I i -tio°1 Date)
ttadt u1�c�oeal z[xr!;'�ale ez z:-::;i:'r. -:!e ca'rina•t w::t:.Yatn:r�• li erc._adn:-)
X 'toll IL :>olc ;;roprieLol znti have no one avoriu,"; for me, 1 f G
( } I am a home, Dci_;b-. mn all Ole wor: ;`;celr. .{� ph1�
Ar'O rl::plc:-sc be n«a;c tTta:•.4i_:ic lri<:,ca�+:r_rs��;�c::.,�!oy tx:z;;r t4 t.>u..x:rtr;ink cY:. r,:c�:m cs gar:. =f i..�::L�.cili: cE
not tncvc th_n throo ui:itr ir.%;Lch !t c t rk ntirs res:-_Y or at uSc VF-_.:nhz Ltccto r c nc<c:cr r2Tl_:
cmploycrs u__)j4s tlr.+v ;i':_,,:C, _-rte;nticn Ac (GL.152r 10)),nppliczticr.by a hot:uoca xi`.or a l:r.x
legal etatus of an xttployot under tL-o Workee.cnmpan4tion Arc
1 unde.^ziand thit a copy of this rite:; RLy bo fo,nrdo j to tbo D--txirt.—d of lndxL tree!A,,66.,&Clt;oa of!: ua>_a Tot tlm
coventge vrriFieatioa and tb--t fall;=to f-atrc covcsabs tu:L r:eaion 25A of k(GI,152 can ic-d to the im�sitian of r nin T pct iii?es
ooasisting of a fine of up to S 1.500.00 a:?�'cx imi riuxm).,1 of up to on-.yt r P"M civil perultin in�c form of a Sic-,,Welt C},`":arc1 e
frtc of 5100.00 i d+y agin:.t tm_
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SECTION 8- 6148000 !qWSERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e en Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1Q1110RKERS'yGOMPENSATtON 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 affida�
will result in the denial of the issuance f the building permit.
Signed Affidavit Attached Yes....... MZ No...... O
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings.of one(1) or two(2)fami!ies
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
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: ,A9�'/oZ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet 0
al �Fe o't
NMI i' i f'oii 0 ezistiii; 7707-T-9- i t f E11or m
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? _
I. 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 N
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? _ Yes No .
1. Septic Tank City Sewer Private well City water Supply
� llT,# OIZATLON TO%BE COMPCE TEED WHEN
QNEFt x f.. C1ORiAPPL 1ES FOR BUlI DING PERMIT
as Owner of the subject propert,
hereby authorize — GF-with to acs
my all matters rela ive to work authorized by this building permit application.
d
SignatulgEwwrier Dbte
as Owner/Authorized Agent
hereby deci a that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge Nd beliefs
Signed under the pains and penalties of perjury.
Print Name /
_ L(43
Signatu of OwnerlAgent 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
J �/r
Frontage
Setbacks Front
t �
Side L: R: L: /0 R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking) j
#of Parkin Spaces X!
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ev r 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: "4!5-�F_V Ki�L�
D. Ar 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
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR D ; L`f 1NELLING
1 .
SECTIM 1 -SITE.INFORMATION -f�P ;n;+is
fp Th►s .,� x� �,,
1.1 Property Address:
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APPLICANT/CONTACT PERSON STAR NORTHAMPTON INC
ADDRESS/PHONE 36 KING STREET (413)584-x4Qa-o uC'g���l o?/ '/�j•Q"L
PROPERTYLgCATION 36 KING ST
MAP 32kL TA CEL 255 001 ZONE CB
THIS 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: ERECT 10 X 12 SHED _
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 FOLLOWING AC ION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P ENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ AIR
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan —"+7Ac"C
Major Project: Site Plan AND/OR Special Permit With Site Plan Gfr SS jW.I*
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water.Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission _ ermit from CB Architecture Committee
Permit from ElWStr t Commission
/ t
Signature of Buil mg Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.