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35-203 (3) t �CIIAMPT0 - $ B �lssasch«setts m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AAFU'MAVTT with a principal place of business/residence at: o (A=Ucity stalrlrip) o 10(p Z do hereby certify, under the pains and penalties of perJury, that: O I am an employer providing the following worker's compensation coverage for my employees worEng on this job: (Insurance Company) (Policy 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) (Insurance Company/Policy Number) (Fxpimtion Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional slxet if mccnixy to include infortnarion pertaining to all 000tr fs) ( r) I a sole proprietor and have no one worlisng for me. I am a home owner performing all the work myself. NOTE:please be aware that while homcovnm who employ pcnom to do mlk�construct oa or repair work on a dwelling of not more than throe units in which the bomaowncr resides or oa the gtvunds appurtenant thereto me no(generally coesidcrcd to be employers under the worker's oration Act(GL152-"1(5)},application by n homcownct for a Uc=c cc permit may-idcace the legit ctatua of an employer under the Workeez Compensation Act_ I understand that a copy of this ctatcmcut may be forwarded to tbo Dcpertr.�of Di al Aocidcr,&OM oo of in—for tho coverage verification and that failure to secure coverage sunder sociioa 25A of MGL 152 can lead to tho imposition of criminal p-&Wcs oonsisting of a fine of up to S1,500.00 and/or i mp riso�t of tip to one year and avi pcaaltia in the form of a stop Wort:Ord--and a Sim of:S 100.00 a day against mc. * Foe dgr-t use only permit Number Lot i`{ iPatare of LiccnseclPermittee Date �. v10N 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 affidE 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)familic 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( 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 cal Zoning Laws and State f Massachusetts General Laws Annotated. Homeowner Signature SECTIOND�ESCRPT PROPOSED1NOtK cIIEa' litalilej New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: rc C'{ S H c S f' , Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ °'�IfNeho��`ise°' an+dotldit�on'to° ez�st�n hof�sin�.�c`omple'.tethe.r#o11o'wi; : 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 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 OViINEReAUTi �ORIZATION TO BE COMPIETED WHEN OWNERS AGENT:"QR CONTRACTOR APPLIES,-FOR BUILbIIVG PERMIT as Owner of the subject proper hereby authorize to act my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I , 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 penal��'esp f perjury. Print N e Si a re of Owner/Agent Date Section 4. ALL INFORMATION MIDST 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 ize 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: t ity of Northampton t l� uilding Department ' 212 Main Street 1 Nd'` 2 ant Room 100 {. No hampton, MA 01060 of Btsl�GsN�tt gl%S413- 87.1240 Fax 413.587-1272 =a e DEP��T��yP50h.M.A 01060 � e =et;3 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1',- SITE;INFORMATION Thts secttotito}becomple#edbyoffi�ce 4 1.1 Property Address: .�r Y �sP�3 �� ��Ph k-_ ,� Map h 11nt Lot t � s Zone gONerlayDtstrtct Elm St.District CB Ristrict SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1_Owner of Record: 1 r ;3 / [ W rint) x Current Ma�ing Addre � —6 Z ' '" Telephone 111 ��— `1'7 2 L( x I d Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION CC Item Estimated Cost (Dollars) to be Official Use Only completed 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 =(1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Pernnit�Number: Date Issued: Signature: �pt� Building,Con�missioner/Inspector of Buildings � Qt cis°llT? BP-2002-0556 CIS# COMMONWEALTH OF MASSACHUSETTS � CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: roofing BUILDING PERMIT Permit# BP-2002.0556 Project# JS-2002-0854 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq. ft.): 52272.00 Owner: WASLICK MARK W&SHERRI A& Zoning: SR Applicant: WASLICK MARK W & SHERRI A & AT. 1280 BURTS PIT RD Applicant Address: Phone: Insurance: 1280 BURTS PIT RD (413) 586-6042 0 FLORENCEMA01062 ISSUED ON.•11129101 0:00:00 TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER 1 EXISTING LAYER 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 11/29/01 0:00:00 1218 $25.00 212 Main Street,Phone(4 13)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo