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32C-304 (4) 0.(1lN-f P", Fro 0�`E Crif-�) of 'Narflla111}Ttoil Q e Qtasanchncctte d DEPARTMENT OP DUILDf�'\'G INSPECTIONS 212 Main Strect ' Municipal Building Northampton, TJass. 01060 WORKER'S COMPENSA'I'DON INSURANCE AFIqDAVIT (]i ccascr_/perrn�ttcc) \with a pf-mcipal//place of business/residence at: j`�� ks�N.F _-/`mot ✓�'' fe- r-iA : y►�✓ (phone ') + �3�_ f6 i� (Sum4wci ty/slalcfzi p) do hereby certisj;, under the pains and penalties of perjury, .hat (/am an employer providin^ the followim-, worker's comocnsariou cove 2^e for m eluplovecs worming on this job =C-- Com=Y) (PoLic: N-u-alxr) (L;piruon Dztc) ( ) I am a sole proprietor, general contractor or homeowner (circle one) amd have hired the contractors listed below wk h2ve the following worker's couipensadon policies: (Name of Conrracw-) (In�rancc Cotnoan}ii'ciic, �'um r) (I-�pirl;:on Datc) (Name of Con(ractor) --- anstrancc amoaa-wPolicti' Number) (Expir,Lion Date) (Name of Contractor) (asuranc: Company/Policy Numbzr) (Expiraon Dale) (Name of Contractor) (Rnsuranc-- Company/Policy Numbz-r) (ExpLjauon Datc) (t torch ad i�ocil c'.xa f acccs.ry co me u informs oc pert..inins to.L ocm aco�) O I am a sole proprietor and have no one woridog for me. ( ) I am,a home owner performing all the work myself. NOTE:plcsc be' -auL th-:ut:Jc 6la 'DCr "to employ pc;z w di cz m-t�=-✓.-urc oo c�mpau..ork on of ON tacec tbnn t _La'u in wb ch the bo mm�ver mides oc oa the pround,zppurtc-av�j tbcc.o LT oa ltircrally ocrJid-y d to be emPloy—unGc the"-km-'s camp—loo Att(GL152.s 1(5)�nppbjmbon by n hotncoavct far:lica`v_a Permit rr y e idcncc the 1egJ"'tx"of to cm*Yy under din Wolk; el Co, al AL I underhand slut a copy of this aatcm,mt m.y be foc?mrded to tbo Dcpartmcna of h du,S,id Ac &d Offioo of tnnirzooe roc th. oovazSc vaiLcaioa and that f_iltac to tcauc l-ovRy&C uDdcr soclioa 25 A of MOL 152 can lad to tha inr�on of ai-iatl PcnA-Wcs ooali-,a g of a fine of uP to S 1-500.00 ardor o f up to oac year tad aril pcaOua in tSc form of n Stop W(A Order tad a rim of S 100.00 t d_y test u e For d p.rcm u,c ody Permit Number vr-rou 1,4�3pt; _ Lot Signature of LiccrsscrlPcrmi SECTION 8-'CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �d' ©8'(<P I/e, License Number Address Expiration Date Signature lVelephone N . t Not Applicable ❑ _ Company Name V Registration Number 99-/ �2; � t!� 06 -/�5f ).pad... Address Expiration Date YO ,,?TIA enp-7 0 Telephone 'SECTIOIV iC-woRl{ERS'COMPENSATION INSURANCE AF,FlD"IT(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...... ❑ 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 1 aplaligabl New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Ro;ping ❑ 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❑ 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 -OWN A"THOIIIXATI7N -TO BE,COMPLETED WHEN OWNERS AGENT 02 CONTRACTOR APPLIES FOIL BUILDING PERMIT Ac� � S as Owner of the subject property hereby authorize 9,q, to act on my be in II matter elative to work authoriz d by this building permit application. © U W nature of Owner 7 Date w /9 as @QW/Authorized Agent hereby declare that the statements and infbrmation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ,e Lo Print Name Signature of Owner/Agent I 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: 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 DEMOLISH A ONE OR TWO FAMILY DWELLING SECTI©N:1 SITE INFORMATION 1.1 Property Address: O� rn SECT , N 2-PRI PERTY:OWNERSHIP/AUtHORIZED AGENT 2.1 Owner of Record: PIA I Name rint) Cur�rgnt Mailing Address: { /VAa m A ,-),2 76 rJ YI'4 A' 1 Telephon—e 17 Signa ure S9-7— ©� 2.2 Authorized Agent: )) Name Print) Current Mailing A dress: ' J X517" Y16 Signature Telephone SECTION 3 JEttIMATED CONSTRUCTION C lSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical �. (b) Estimated Total Cast of Construction from 6 3. Plumbing ,. Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4 +5) S7G Cheek Number This Section"For Official Use Only Building Permit Number: Date Issued: Signature_: Building Commis oner/Inspector of Buildings date 7 VALLEY ST BP-2001-0405 G1S#: COMMONWEALTH OF MASSACHUSETTS MM.Block; 32C-304 CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Category:vinyl siding BUILDING PERMIT Permit# BP-2001-0405 Project# JS-2001-0682 Est.Cost: $4570.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sg. ft.): 9931 .68 Owner: PASQUALES ANDREW Zoning. URC Applicant. B & R Sidinq AT: 7 VALLEY ST Applicant Address: Phone: Insurance: 781 Bridge Rd. (413) 586-4167 Workers Compensation FLORENCEMA01062 ISSUED ON:10 1I8 100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL 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: 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 10/18/00 0:00:00 17333 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 7 VALLEY ST BP-2001-0405 GIs#: COMMONWEALTH OF MASSACHUSETTS MaR.Bl k:32c-344 CITY OF NORTRAMPTON T Permit: Building Catem:Y-iu1sides BUILDING PERMIT Permit# BP-2001-0405 Project# 4 -2001-0682 Est.Cost; Fee:$25.Q 0 PERMISSION IS HEREBY GRANTED TO: Const.class: Contractor: License: Use Groun: B & R Siding 1004465 Lot S' sq:fl} 9921.6$ OWner: PASQILALES ANDREW Zoning:OW Awlicant- 8 & R Siding AT: 7 VALLEY ST Arrnticgn1-4ddr Phone: Insurance: 781 Bridge Rd. (413)586-4167 ke War rs° COm nsation FLORENCEMA01062 ISSUED 2N.-10118100 0:06:60 TO PERFORM THE FOLLOWING WORK INSTALL VINYL SIDING POST IRIS 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: Ok /f- a THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES ZAND REGULATION Certificate f O u Si nature: Fee Type: Receipt No: Date Paid: Cheek No Amount• Building 10118/00 0:00:00 17333 $25.00 212 Main Street,Phone(413)587=1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo A�