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35-157 4-�l�pTp � pfl Crzt� of wart 11aillp#1i1 BB �1:saachnsrtta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFM+IDAVTT I, VZZA I 01J�-H A eV Gi=see/permittee) with a principal place of business/residence at: 0146— ✓ ,IXA GYD (phone (streetici ty/s�aie/a 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: (Insi=cc Company) (Polio Number) (Expiration 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) (Laurance Company/Policy Number) (Expiration Date) ,, (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Nagle of Contractor) (lat=e-- Compaay/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach addlt co 21 sheet ifnecczury to inclUdt infocrostion perdrining to e11 ooatm ors) �I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that whim homcowncra who employ pcaom w do m- • mastrL=cmn Cr repair work w a dwelling of not more than three units in which the houioowncr rt=dcs or oa the grounds appurtenad tlxatito arc not Ccncrally comidcr:d to be cmploycrs undo the works',-.compc=tioa Act(GL152,=1(5)),applic3,6on by a homcowna for a U—cc pclmd may cvi&noc the Itg21 stabU of an omployer under tin Workor s Cwnpmsation AcL I understand d ijd a copy of this ctatcmccit may bo forwarded to tho Dcpartc c of I.odus4ial Acad--&Oflroo of Insunoco for the coverage verification and that failure to secure ooverago under soctioa 25A of MGL 152 can lead to tho imposition of criminal penalties ooasistiag of a fine'of up to S1,500.00 andloe imfuisoumcut of tip to one year and civil pcvattics io tic form of a Stop W ode Ord"—and a firm of 5100.00 a day against mc. For dq-tinmw use only permit Nilmber ., 02� D2 Map's Lot# Signature of Li ermittce e SECTION 8'-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ` f Not Applicable ❑ Name of License Holder : �!�L� '.1J ' �4.(� N's ` ©4J —56 / License Number Al A , 11\3CA 0-1 4rddres Exp irat not Date e Telephone .;Re B OEM!D. Not Applicable ❑ �r [�r AAf //� 0 01 72" S Company Name Registration Number j�V•® • OX S 6 F osEeU /YEA - S M9- Address // Expiration Date Telephone-,2, 92-- 0©a' 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...... ❑ 11:� I3�ome��O�wner%^`�c��empt�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 - SECTIONS DESCRIPTION OF-PROPOSED�WORK�(check iWapplicable) , New House ❑ Addition ❑ Replacement Windows [A�teration(s) O Roofing ❑ Or Doors X Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: 9C_RZAC C- V..1"A/6 rZ©O m ILA-61/ )0W /Q 55 A J Alteration of existing bedroom Yes_lam_No Adding new bedroom Yes _ No Attached Narrative 11 Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ 6a 3Jf.New 1i"ou"s alid:or tld`irtron=to ezistretjVh U§ir g :complete the following_ 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 CONTRACTOR APPLIES FOR BUILDING PERMIT i, i ti rnc-_& gyc ` " TT IV/n�� !! , as Owner of the subject property hereby authorize (,✓E IV (D=H- AJ _ to act on my b7��all matters relative work authorized by this building permit application. Ge A� L-c-c- — - Sigr(att, of Owner Date I, �I Ae VPIV 0 LX{-1AIV -, 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. ,/ Print Name Signature of wner/Agent Date ,, O� 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 At/A A/AQ 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_ NoX- IF YES, describe size, type and location: D of Northampton ding Department G, r ull u 2 Main Street ' rise ` JUN 2 7 2002 Room 100 a F,w . v orth mpton, MA 01060 o etas° a DEFT OF BUILDIN 0 3-5E7-1240 Fax 413-587-1272 A.o lS�ite N.d s NORTHAMPTON,MA 01060 QeiSpec�fy _ APPLICATION TO CONSTRUCT, 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 offtc� �< A nl R O Map ! Lo# that VIA Zone Overlay Distnct .� _ Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam' Print) Current Mailing Address: Telephone gnature p .515S - 2.2 Authorized Agent: go MIA. OXZ"Al Name(Print) Current Mailing Address:zz ?::2?z f 6 {— no 0 — Signatur Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building '�� fl00 (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) IF 44,dDo Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings ;, Date . BP-2002-1183 GIS#: COMMONWEALTH OF MASSACHUSETTS mot. CITY OF NORTHAMPTON Lot:-001 Permit: B u i l d bg Category: BUILDING PERMIT Permit# BP-2002-1183 Project# JS-2002.1894 Est.Cost: $4000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Steven Olihan 117097 Lot Size(sa. ft.): 47044.80 Owner: RICHI JAMES R&ANNA M Zoning: SR Applicant: Steven Olihan AT. 824 RYAN RD Applicant Address: Phone: Insurance: P O BOX 86 (413) 268-0005 () GOSHENMA01032 ISSUED ON.6/27/02 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE LIVING RM WINDOW 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 si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/27/02 0:00:00 154 154 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo