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I r r 14 ` 0-3 Vi, z � I �z a75:�3` w a� i r i I i l I _ ff rte, i O O of Nart4amptan � e �lasasrE<asrtta: DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT L J©HA( Wr 11AP-D (licensee/permittee) with a principal place of business/residence at: 53a i'uiNFY 444 -Hf?AT(-68096 A V7- o53oq (phone# $Oa) L�58'65L.5 (street/city/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: �GONOMY -�NS•�D. AMER�6AAI 01-we--885595-dD 09101100 (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 worker's compensation policies: (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) (Name of Contractor) (Insm7anc a Company/Policy Number) (Expiration Date) (attach additional sheet if neocnary to kwJude information pertaining to an ooatractora) ( ) 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 whilo homeowners who employ persons to do maintenance,const action or repair work on a dweUing of not more than throe units in which the homeowner raids or oa the grounds appurtenant thereto are not svxmily oo=derod to be employes under the woriceet's oompe nation Act(GLr52,ss 1(S)),application by a homeowner for a license or permit may evidenoc the legal ctabu of an employer under the Woridees Compensation Act I understand that a copy of this uatement maybe forwarded to the Depa tmco2 of Industrial Aocidoa&Offioe of Irnavanoe for the coverage verificatioc and that failure to awure coverage under section 25A of MOL 152 can lead to tba impositioa of criminal Ptmalfics oonsistia= a fine of up to S1,500.00 and/or imprisosm of up to one year and civil pemzltia in the form of a Stop World order and a fum of s a day against ma. For dq=ftneatat wo oaty Permit Number X $-ZZ'2000 Permit Lot# Signature tf Licensee/Permittee Late - .emu b 90 J0N 1-CONSTRUCTION SERVICES . 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ©64/t✓ ��!]R r�7 y� (p License Number 3 51 Poo L ChAm }�� , In�eSt 6 4 rsfL-2FIELb Al o3yy, I /g ;,00 Address Expir tion ate 6s3 3 � 3- �9 a Signature Telephone _ nn Not Applicable ❑ tDlf�Z �F SVAY /'ZV X37 Company Name Registration Number 53Z fo L Addresses p '/ Expiration Date I► 05J�Q Telephone Jd2- S`ET[1}T lfa-WtIFtKI_!2S'CQM, ENSATiQ ! INSttAMCE AIDAVIT(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 Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 1 IQN 5- DES-CHI EIION 0 d S ec 11 a New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other N To Brief Description of Proposed Work:&mpyi Cp Ttl & eRI-EAIS 0W POK60 I A16TAI 60DI)JG _A y5 W �Do i'Rnl E�5 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ Who s.a�& d 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? ew�- 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 ECTjQN 7a -::OWNER AUTHORIZATION;— TO B COMPLE'T'ED WHEN OWNERS AGENT OR CdNTRACTOR'APPLIES I:OR'BUILDIING PERMIT 1, ��`a \�a�\� ` �t��.�� ('�t��f_ , as Owner of the subject property hereby authorize DkV VVt��FY(LD to act on my be II matte s rel tive to work authorized by this building permit application. 9- 22 - 2-000 i ure wner Date 644 I LL JJI as 9wrffr/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. 001% �'l Print Name Signature ofar/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 0"I 7-:a Ff. Frontage Setbacks Front Side U231 L: R: 'T Rear �75��,3 a-75 13 ' Building Height :;z 0 2-0,0 Bldg. Square Footage ' cb56 % 'l SSb � Open Space Footage % j (Lot area minus bldg&paved ax #of Parking Spaces 3 Fill: r A /S A 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: �~ &ity of Northampton BuiNding Department 2 •.;�� :�2 .Main Street ; Room 100 �'Northampton, MA 01060 IA one 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 FThis sectign e fll 1.1 Property Address: 130© BUR-TS Kpi41� Map FLz�nek yr,r ■f y..y.2' � a r' r�s� 'i SECTION 2 rIPROPER'TY OWN ERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: %3Qa BGIR-rs 0A L 1ose,P14 I LIMILL 110N NA 14 tS 6 FL.ORCAX6, /A4A ono(o2- Name(Print) C irrgn3KQailin� 75 Telephone Si 2.2 Authorized ent: /. o, -Box S36q J-9 AV 8 0 , A A D -3Rp7fLE*9oRo, VEAM0,4 Name(Print) Current Mailing Address: ( 80?,) a59- Signature Telephone SECTION ESTIMATED CONSTRUCTION°COSTS Item Estimated Cost(Dollars)to be Official Use 0,rfl:, completed by ermit applicant 1. Building �(a)'Building Permit Fee , 1 2. ElectricalQ® (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) CheckNurnber G7,. This Sectialn For Official Use Only Building,Permit Number: 13 Pry! �a''' bate Issued: Signature: Dad Building Comm issionerflnspector of.Buildi9gS , File#BP-2001-0202 APPLICANT/CONTACT PERSON FOUR SEASONS SUNROOMS ADDRESS/PHONE P O BOX 8304 (802)258-6565 PROPERTY LOCATION 1300 BURTS PIT RD MAP 35 PARCEL 201 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid = Typeof Construction: REMOVE SCREENS&INSTALL SLIDING FLASS WINDOWS&GLASS PANELS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 074516 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: 1 Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee 8 L5� Zoaa Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. 1300 BURTS PIT RD BP-2001-0202 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 35-201 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0202 Project# JS-2001-0325 Est.Cost: $17206.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: FOUR SEASONS SUNROOMS 074516 Lot Size(sq. ft.): 46609.20 Owner: MEISSE DONNA&JOE HAMILL Zoning: SR Applicant: FOUR SEASONS SUNROOMS AT. 1300 BURTS PIT RD Applicant Address: Phone: Insurance: P O BOX 8304 (802) 258-6565 BRATTLEBOROVTO5304 ISSUED ON:8128100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE SCREENS & INSTALL SLIDING FLASS WINDOWS & GLASS PANELS POST THIS CARD 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. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/28/00 0:00:00 2984 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo