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35-115 (4) * A �"" '7M� a 0StiAMP� � � �aaachuastta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S/Cy OWENSATTON INSURANCE AFFIDAVIT 9J f (Iicensce/perfnittee) --'"" with a principal place of business/residence at: Z- —�hyv �U�• (phone#) — �� (street/city/swdZip) do hereby certify, under the pains and penalties of pegJury, that: ( ) I am an employer providing the following workers compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Poricy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (anach ad&tioml shed ifneceswy to ine}ude information pertai to all ooaba ) >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 swam that vrhilo homeowaera who employ pawns to do main}M•n ,�uctioa or rcpaa work on a dwelling of not more than thme units is which the homeowoer resides or on the groun6 appurtenant thacto arc not generally oo=dasd to be auploy—under the worlc a comp=seica Act(01,152,s I(5)),application by a homeowner for a license or permit may evidence the legal&lama of an employer under the Wodeees C.ompensdion Act I understand that a oopy of thin ztatemeat enay ba forwarded to tho DeparwxuG of Indust ial A m&a&Ofhoe of Insur*aea for tha roll coverage verification and that failure to secure coventgo under soctioa 25A of MOL 152 can lead to the i on of criminal penalties ooa&L,6ng of a fine of rep to 11,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Work Order and a firm of 1100.00 a y against me. For oaf) um tuo Permit mkt Number M�-Ut# Si of Licensee/Permit3ce e G'TION$ �3N$TIMUCt1.4N SERVICES _L L Licensed Construction Su er ' on Not Applicable ❑ r ' Name of License Holder :_ � t11 1. C r�J �l:Vi l o <-4, }— License Number Z TI�O Q '3 Address /! Expiration Date L Signature Telephone . a. fN.� Not Applicable ❑ RMN U r, CN 1On 21g Company Name Registration Nu ber o F_ Address Expiration Ilite Telephone -1 SECTION';10 ,WOkKERS'.CC3MPENS ITIQN 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. ned 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 - ;,R PU ! h e New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: r Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative❑ Renovating unfinished basement Yes "_No Plans Attached Roll ❑ - Sheet❑ ,.. ; rM 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? 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 BWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT J C as Owner of the subject property hereby authorize to act on my behalf, in all matters rilathe to authorized by this building permit application"kf k/ Signature of Owner Date C � 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. elk under t pa' sand pe alties of pe ' r C L �G✓ � Print Name 1 410 tf Signature of Owner/Agent Date 1 f 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: H- 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 X 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: w a,4 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 SECTION 1-SITE INFORMATION : T,h!s sec. i � com tfi�ffl . 1.1 Property Address: l N —} /1 Me f.ot � r /ilk o low clay E ms . Kip a 41111-00 ' SECTION 2 PROPE121Y OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Record: ��;�J h '�Z S'�h -VCnW Ave o,V me(Print) Current Mailing Address: Telephone Signature Cy 2.2 Authorized Agent: Ave ^ v 32 �' caw A Name(Print) Current Mailing Address: tjoUA CkT Signature Telephone SECTION 3 `ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building — �-c� .cc) (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 Dumber This Section For Official Use Only uilding Permit Number: Date Issued: Signature: Bul,lding CornMissloner/Inspector of Buildings Date ��; �,` f *�. ,E i i ,�:, ; ,��,- �� .�. �: 17 FO RUST GLEN DR BP-2001-1082 COMMONWEALTH OF MASSACHUSETTS Map:Blo k:29-115 CITY OF NORTHAMPTON Lot:-001 + Buil�ting i BUILDING,PERMIT Permit# EIP-2001-1082 Project'# 18-2001-1907 Est.Cost:$3500.Q0 Fee:,$25.o PERMISSION IS HEREBY GRANTED TO.' Const.Class: Contractor: License: Use Group: Paul McCutcheon 100218 _k :Lot 5j*1%A 139§2.76 Owner: MCCUTCHE©N PAUL C&MARCHELE Zoning:URA A, & nt Paul McCutcheon AT: 77 FOREST GLEN DR AuylicantAclrlre9 Phone: Insurance: 87 Chestnut St (413)584-3352 FLORFNCEMA01082 ISSUED ON.-§20-101 0.40: TOPERFOR THE FOLLOWING WORX:STRIP & SHINGLE BACK ROOF & L3 - EO ;FIO4F 3 OST IT IS VIS LE&OM ME STREET Inspector of Ptumbing Inspector of wiring D.P.W. Inspector of Buildings Underground:` Service: Meter: Footings: Rough: Rough: House# Foundation: - Final: Final: Rough Frame: 'Gas dire RR rtmeut Fireplace/Chimney: Rough: iL• Insulation: Final: oke Final: OK 6-1-®/, ` ' THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VI O ON O ANY OF ITS R AND REGULATIONS. i ica of Oc` t e: ee- e: Rece' Date Paid: Check No; Amount: r Building 6/20/010:00:00 4930 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo