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32C-289 (2) i 4TItAafp�O g�a e� .'`g (rx� iorf �ax#E�tt11t�t�II1T - - �a36athtlStltS DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORYCER'S COMPENSATION INSURANCE AF AVIT (licensee/permittee) with a principal place of business/residence at: '? ;,�(�"y —�/`� - � ���✓'n✓+ � (phone#) -3y���''_'�";, %' (strret/6ty 1sta1d7* 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: (Insi=ce Company) (Policy Number) (Expiration Date) ( ) I am a sole prop:�etor, general contractor or homeov mer (^rcle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Compairy/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Insm-,mce Company/Policy Number) (Expiration Date) (attach additional sheet j noccs to include inforn x6on pertaining to ell ooatrn rs) i ( �am a sole proprietor and have no one worming for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whilo hooxownera who employ pazom to do ms;,,r .,,n o=st,u oo or repair work oo n dwelling of not more than throe uni s in which the homoowncr-resides or oa th.c groin qVirtenant tht:d ere oot gcoaally ooaridcrcd to be emPloyas under theµor'j!es ccmpc=tion Act(GL152,=1(5)),application by a homcowns for a license cc permit may cvidcboc the legal ctatua of an eanptoyer under the Workces Compomation Act I understsad thst a copy of this municat may ba forwarded to tho Dtpart�of Industrial Aradw Offioo of Iaarirsooe for the coverage vaification aM that failure to acc=covaago under sectioa 25A of MGL 152 can lead to the imposition of criminal Penalties oomisiiag of a fine of tr,i to S 1 500.00 and/or impiisotmxut of uP to ooe year and ava pensltia in the form of a Stop W orb Ord,-and a fmo of 5100.00 a day agiusl M For dcpsrW'.- l tuo only permit Number { Lot i,r 1 SiPature of Li ermittee e - r 6D�N, 8 1 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder : 6'/%'� —a!/ 9P�?�` n 6 License Number Address Expiration Date -6-2 7 o" Signature Telephone e Vii; m r. v men .roy n r:' r Not Applicable ❑ Company Name Registration Number X—' fie _r/. ��r�?�"�4r� /l,T� , ��G 7 `�/ f f 2- Address Expiration Date Telephone �� �`��% SE9TI0,N;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 affida 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 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 haws Annotated,you may be liable for person(, 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 x'i e % ��'�, �SECTION �SCR PlI:O PRO O.SED OR�K �' c aka licable ��,"i�`x`i��'"�' '�.aq#�*z. .xw' s„��"v-k'"u�,1��'Pik°n� :.., "�Y.,.``1YSS�'�?�'i�t�,'t '•N�"� N��'iril i�: s ud�" 5,��r''H •,�r"� F , .u.., ; .. ,.M �k$3d'v5�"`.,.�» :, �, �� r,w�si.....�..m;,fit aF'e;��'""•,."a.., ,...r� „,�'..,,�3( ....N ;: 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 Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ ff New hou etand.o addit to a 1st>IMU70Jiisin AN't ple h— 611.0 : 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 I 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 7aOVIINER AUTHOR(ZAT10N 4 T©CBE GCMPLETED -WHEN 01NN RSrAGEN '01t CONTRACTOR pP1,11=S FQR UILDING- IIE M1T as Owner of the subject propert hereby authorize � rfsa✓ to act my be If, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, C� /'W f'? as C /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 Signature o (/Agent Date s 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; - ,`, ; Cit f orthampton i �jBui Department ain Street m 100 I LAi;AL40 on, MA 01060 MA Fax 413-587-1272 P o# 5tel' �Qt�er=Spect APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be com letetl by M66 fl 1.1 Property Address: a �� l )y Zone O�erlayDis# c#* ML w Elm`St. District CBDistrict`"- " SECTION?2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1'�aiil�i, itit) Oulieilt Iviaiiing Adch t @bs. Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION 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) Check Number This Section For Official Use Only Building Permit Number: Date Issued: ,Signature: Building Commissioner/Inspector of Buildings Date LIAS,+ BP-2001-1067 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofin g BUILDING PERMIT Permit# BP-2001-1067 Project# JS-2001-1888 Est.Cost: $1473.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DE Sheppard Roofing 105885 Lot Size(sg.ft.): 5880.60 Owner: HALL JOHN B&HELEN I Zoning.URC Applicant: DE Sheppard Roofing AT. 134 WILLIAMS ST Applicant Address: Phone: Insurance: 17 1/2 Briggs (413) 529-0170 EASTHAMPTONMA01027 ISSUED ON:61191010:00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE MAIN ROOF & BACK PORCH 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: Rough: Rough: House# Foundation: 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 6/19/010:00:00 2223 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo