Loading...
35-276 (12) 4�tM L4P oy <Lx s g Crzf� ;of 'Naz#4ttntvtou M � e ,�lassarllrrsrtls DEPARTMENT OF BUILDDgG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFMA.VTT (licenscdpermittee} with a principal place of busine residence at: 1 �1�i 61T 5T' �2� I'f. 0 035 (phone#) -` 2 I 17 (street city/statrJap) 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: U© ;L ,-`7' l (Insurance Company) (Policy Number) (E4ira on Date) ( ) 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/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/PoEcy Number) (Expiration Date) (Name of Contractor) (Insurance Coinpany/Policy Number) (Expiration Date) (auarh additional sheet ifncarssry to include infunu m prstaining to ell cmtrt ctors) O 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 while homcowDc a who employ persons to&m in�ceasr on cr rpair work on a dwelling of not more than throo units in which the homoowncr resides a on tho grounhs appurtcaarrt thtrdo arc oot Saxrnlly oow datd to be employeta under the vmrkcr's aompcnsation Act(GL152,ss 1(5)),application by a homeowner for a license cc permit may evidcnoe the legal slat,of an employer underthn Workde Compomation Act I understand that a oopy of thin rtxtcmcnt may be forwarded to tho Dcpertm cd of Industrial Accidcnta'Offioo of rnwranco for the oovera verification and that failure to aeauo ooverago under stctioa 25A of MGL 132 can Lad to the impasi6On of ere !Wl pen&Wcs 1 oomistirrg of a fine of up to S 1,500.00 arrllor izrr{tt iso of up to one year and civil pcsulti cs in the form of a Stop Work Order and a firm 0(5100.00 a clay against tn.-- For dcput nt-td—only �- � Permit Number --------- Map# Lot# Si of UoanscelPcrnuttm ENERGY CONSERVATION APPLICATION FORM FOR LOW-RISE RESIDENTIAL NEW CONSTRUCTION Applicant Name: Qcy j 11- �2(C-) 1Iio 3jtcl Site Address: U t j4)6)�G�/Ys-�i� k' L�� S Applicant Address: !L D4.,)t 667- 5i. City/Town: P7>1 I fYF'T7--7 N2 D Use Group: J­f A— Date of Application: Applicant Phone: 19/O 3 Applicant Signature: L, t Compliance Path (check one): Prescriptive Package (for 1- or 2-family residential buildings not heated by electric resistance) Fill in all values that apply from Table J5.2.1 b: Package Number(A through KK): a. Gross Wall Area sq.ft f_ Wall R-value R /7 b. Glazing R.O. Area ?> 8 sq.ft. g. Floor R-value R- — c. Glazing% (b _ a) % h. Basement wall R- d. Glazing U-value U- i. Slab Perimeter R- e. Ceiling R-value R- U i. Heating AFUE `� 3 ✓�� ❑ Component Performance(Manual Trade-Off) Climate Zone(from Figure J6.2.2) 0 Zone 1.2 Zone 13 Zone 14 Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet, if applicable] MAScheck Software Attach Compliance Report and Inspection Checklist printouts. Systems Analysis ❑ Renewable Energy Sources Attach approved Analysis Official's Name: Official's Signature: Application Approved F� Date of Approval: Application Denied Date of Denial: Reason(s) for Denial: (over for more) BBRS 12/007 t A 0Q C� pTO `e (rrt I of 'Nart4alliptalt � � 6 �assxchusrtte — DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' Square Footage Amount Basement @ .10 13 3 U J 3 �u 1st Floor @ .40 I 3 3 U3 2 cv 2nd Floor @ .20 1/2 Floors, Attic, Garage .10 s ��, Deck, Porches .10 v TOTAL i. ` �.�•:..... 1 WETLAND ............. \.1 ICI ... 1`. ,1{r;..' �... s. . \ ................. ......... -280 :.. .'.'...�.. ... ..� . . . ' AREA...... ...........:.:. .::......•:: .0'..... ... ._ — �... ...... ....... .. I{I;. .. ......` ...\.. .. ,.' ........ . — ..... ....' ....FER: ....... ... . .. ..\.. ...�..•,. �. ZONE.. . . .. .. \ _ �... .. \'..'.' '.,.. ..... ............... ........... \ \ i \. 40.OQ 40. \ �. . �. �. ......... �. .. .� . SIDE SETBA SID& E BACK \�...'.'.'.. .�.�.. ... .r:;.................... .'. .. .. 9.5 `.... . . ...... v..T....... .. ... . . . PROPpsEd HOUSE\ I\cna,icE JAMES F.__POT M— - FF: 1 \ SNO. & FS; \ 5 / 2ee.s 1 {� 286.3, PATRICIA A BO / 2 ; TAX MAP 35 - LOT 278 4 00' BOOK 4822�PAGE 216 / SIDE 0G + g �- S \\ O / J "1 '� 41 A D I 2 6.5 '7 BITUIY INO S ��� ° \ I c PAVEM o -_ 286 00 T f 1 s j �N K15' / I 1 ( ( --- 1 --- 11 0 �� ( I ( I l L=150.92' - - - -- -- - -- - G�-6�0 `Z �0AItK\ , - - - - - - - - -- - - - - - -288-