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32C-304 (5) 04� MpTO B 8 DDW11Y�JIIIt 6 d �lressncf[nsrtta' m DEPARTMENT OF BUILDrNG INSPECTIONS I 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT PX r&V✓ It � (hceSt'J- pemuttee) with a principal place of business/residence at: V A 11t v (phone#) 07Z V (str=Ucity/statdzip) 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) (Policy Number) gE)#raticn Date) ( ) 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) f. (Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sled ifna c=x-ry to include infvcmaiion pertaining to all oodradora) ( �)� I a sole proprietor and have no one working for me. (tor'l am a home owner performing all the work myself. NOTE:please be awars that while homcownera who employ pasont to do mamkuaac,const u oa or rcPair work on a dwelling of not mom than three units is which the homoowacr rc=dcs or on the gourds appurtenant thereto arc not gc*=4 oonndered to be etnployera under the works ooapcas4on Ad(GL I52,ss 1(5)),application by a homeowner for a Ucense or permit may evidence the legal Futb a of an employer under the Worker's C.ompemation Act. I understand that a copy of this ctatemad may be forwarded to the Dcparw.x d of Ir>du3tnal A=&,,&Offioo of lmuranoe for the ooverage verifie non and that failure to soatre coverage under seetioa 25A of MOIL 152 can lead to the imposition of criminal penalties 000wstmg of a&ore of up to S I,SOO.00 andt0r'impr6o=3cnt of up to one year and civil penalties in the form of a Stop Work Order and a fine of 5100.00 a day agnind tee. For dal use only CA Az Permit Number gyp#__Lot# & of Licensee/Permittee Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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...... ❑ 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 L cal Zoni Laws d State of Massachusetts General Laws Annotated. Homeowner Signature S TIO 5—RESCRIPTION O E,PROeQS9D WQRK:Icheck all'applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing O Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[� Brief Description of Proposed Work: I A S -w 11 orttu 6 r` tot ukll -nc!l 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-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR-iCONT"GTORAPPLIES FOR°'SUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 44. , as Owner/Authorized Agent hereby d are that the statenients 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. 4,,driW Pas It Print Name n ',k CAV P266441 Wo d Sign of Owner/Agent 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. A here any proposed changes to or additions of signs intended for the property ?YES_ No IF YES, describe size, type and location: of Northampton Building Department a Off 2 3 2H I) 212 Main Street Room 100 I DEFhT of BUli.MKIG I(SS ECTI,TIONS Northampton, MA 01060 X4-13-587.1240 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: t Aw 04V A � kwisectiptfycla ► ' X r, SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na rint) Current Mailing Address: 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 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 =(I + 2 + 3 +4+ 5) Check Number This Section For Official Use Only Building Permit Number pate Issued: Signature:' Building Commissioner/Inspector of Buildings Date' #M 7 VALLEY ST BP-2001-0423 GlS#: COMMONWEALTH OF MASSACHUSETTS M.Block:32C-304 CITY OF NORTHAMPTON -001 Permit: Building Category:Ch}nmevrebuild BUILDING PERMIT Permit# SP-2001-0423_ Project# JS-2001-0721 Est Cost: Fee:$25.0 0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use GroW: w5 ,ft:): 9931 .68 Owner:_ PAStJ ULl ANDREW zoning:URC Applicant: PAeSQUALE ANDREW AT: 7 VALLEY ST Applicant Ad k s: Phone Insurance: 7 VALLEY ST _ 413)587-07" NORTHAMPTONMA01060 ISSUED ON.-14123100 4:011:©0 TO PERFORM THE FOLLOWING WORK INSTALL PREFAB CHIMNEY POST THIS CARD SO IT IS'VISIBLE FROM THE�T REET Inspector of-Plumbing Inspector of'Wiring' D.P.W. Inspector of Buildings Underground: Service: Meter: Footings - Rough: Rough: House#* Foundation: Finals Finale Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: moke: Final:p tr If-PI-00 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULATIONS Certificate of cc nc Siggatu re: Fee Type: Receipt Nos Date Paid: Check No: Amount: Building 10/23/00 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo