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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal BuiUng 'o
Northampton, Mass. 01060
WORICEIR'S COMPENSATION INSURANCE A i AVIT
(Ii celiserJpermi tree) -
�vith a principal place of business/residence at.
Cis v'3 .
o,�ex �,� e /ii �.► �z��. ST Lim;:- �y --phone]")
(strrct/cit}/ �felzip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following v,orker�s compensation coverage for my
employees worlang on this job-.
(Inure= Company) (Policy Nl mbcr) (F-),,•p ration 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/Poky Number) (Expimbon Date)
(Nam(, of Contractor) (Insurance Comi)aay/Pohcy Number) (ExT radon Date)
(Name of Contractor) (ln5uranc_- Company/Pokcy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Numlr..r) (Expiration Date)
(aaach add t mil S scd ifnar«uy to ix}u}c informLtioo pertainir_g to all coatrnc.ors)
( I am a sole proprietor and have no one worldIlg for me.
( ) I am a home owner performing all the work myself.
NOTE:pleaac be aware tha vihilc homcowixr-a who cmplay pcxz M to d rrai Ica_incc,cn:rs7-,ICioa Cr repair work m a dwt_l g of
not more th n throo units in wit cfi the homoowvcr mida a oa tlx p o n zppurtcn�nl th,,do uc no(�rn�itly ooandcrcd to be
eavloycra under the wvrkcr's ccavct-s4oa Act(GL152 zs 1(5)),application by a homeowner for a licrase cc pcsm may cvidcoce the
legal ctnhia of an omployeC under thn Wockoet Compensation Act.
I undav nd that a copy of thu rta=cat may bo forwnrded to tho DcQartaro2 of I-strid A.idm&Offioo of Inssusnco for the
covai ge vaification and that failure to sea=covccngo and x section 25A of MGL 152 can lead to the imposition of criminal pcn&Wcs
oomistiag of a fine'of up to S1,500.00 and/or imprisounxnt of up to one year and Civil pcnaltia in the form of a stop Work Order and a
fine o(5 100.00 a day t&&inst mc.
For dcputm dr u,o oory
permit Number
� r/.� rSJ Malt Lot
Siguatltrc o i /Pr-,rTnittn,- e
SECTION 8'-;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : J'.�lZ Y �l�`ti'l Yf 094G,a6
License Number
Address Expiration Da e
Signature � , Telephone
..
19°Registered Home lmp`r`ovemeri t"Co
" { , _ Not Applicable ❑
m 3
Company Name Registration Number
2,tJ,0 Z,
Address Sj Expiration Date
Telephone ell
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 affix
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
1: I3orne,OwnerE eBID, I
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act
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 they,
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
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 _
SECTION`5 DESCRIPTION OF:PROPOSED WORK(check all apalicable).
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: � c 14 ittx 4"" Y2' "Z
Alteration Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet❑
6a �lf-New �iotase°a-d or=addition to�ekisting-hbdu in , complete ahe followini7:
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?
In. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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, 6,444, cis/�/�✓ as Owner of the subject prope
hereby authorize / ,/A X J. to ac
my b � matter �relativ o work authorized by this building permit application.
Signature of Owner Date
44 ;j /.Ei?/�'S � 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.
!teafl'Ay T Y�ivT S f
Print Name
Signature of Owner A 9t% 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
s 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:
V V
t f .Northampton
Status"�of
i ng Department Curb Ccit/ia >_ z:
Main Street SewerjSepticA
4 SEP 1 4 2001 '
oom 100 Water/Well� ��
tha pton, MA 01060 Two Sets'ofStrt�ctura Pas
upl OF Bu' -J-587 240 Fax 413.587.1272 Plot/Sete PIa
NnPIPA P CAN,
'Other�5pecify x, $
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to.be,.comp eted by office
1.1 Property Address:
Map Lot Unit"
Zone Overlay District-
.
Elm St. District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A 4 411 Al /I AW i/z.G'�'y «/f"�-.J
Name(Print) 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
FT com leted b permit a ant
lic
11. 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 d
This Section For Official Use Only
Building',Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I I ACREBROOK DR BP-2002-0297
cis#: COMMONWEALTH OF MASSACHUSETTS
a :Block:29-084 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing- BUILDING ILDINV PERMIT
Permit# BP-2902-0297
Project# JS-2002-4447
Est.Cost:$2800.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Gro Larry Yentsch 103986
Lot Size(Q.fu: 12980.88 Owner: COHEN ALVIN I&SHHIRLEY R
Zoning:URA ADDlicgant. rr Ye_ntsch
AT. 11 ACREBROOK DR
Annlican_tAss: Phone: Insurance:
P O BOX 120 (413) 584-4750
LEEDSMA01053 ISSUED ON.917M/1 Q:44:00
TO PERFOM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
POST THIS CAN 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.
Cgrtificate of Ogcu a c s' nature:
Fee Type: Receit�#No: Date Paid: Check No: Amount:
Building 9117/010:00:00 1330 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo