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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(lice�lseeJpermittee}
with a principal place of business/residence at:
(phone#)
(streeUcity/stablerp)
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:
(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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compan y/policy Number) (ExTiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attadt additiocul s.+acct if neecssary to ine}ude information pertaining w ell ooatraciors)
( ) I am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:plcaae be await that whilc hoco owvm who cmplay paiom to do main+ •�0=trvctioa or repair work on a dwcdiog of
not more than thn:o units in w{tich the homoov; c rides a oa the grour cis appurtenant thwcto arc no(guxrally oomidacd to be
employrra undcr the wo k&s wa*a cation Act(GL152,zs 1(5)),application by n homeowncr for a Uccazse or prima may cvidcnoc the
legal tutu of an arnployor under tho Woricode compeasai AiL
I understand that a copy of this rtatcmc 'may bo forwarded to the Dcpartmcuf of I.&L uiat Aoadai Olhoo of Inzauwnoo for the
coverage vc ificaiion and that failure to secure oovecago under sectioa 25A of MGL 152 can lead to tho imposition of criminal pcnaltics
ooruiatiag of a fine'of up to S 1500.00 artdlor im{xiso of up to orx year and avil penalties is flit form of a Stop Work Ordc and a
fim of S 100.00 a day against me.
For dqurtmmtal uio nary
Permit Number
41:f2 L7 t c' lviap*I gn Lot#
�.
Signature of Lic ermi e i
Q
ECry � rsrilp,c'rao ulc
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
.R v 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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
s
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"cert' es and assum responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State aokocal Zonin ws and State of Massachusetts General Laws Annotated.
Homeowner Signature
"
IRO r05a1r :a \
Yea s w V'm C d a 4 a
"?°`,n�. ,.�� ,��,.�h7af�,? .�: �f 3,a..� �' � .,. ��5� ���• �`�»R.r.,�. , ,•..€�>,r.;�'�� �'t:ar
New House 01 Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ // New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No /
Attached Narrative❑ Renovating unfinished basement _Yes V No
Plans Attached Roll ❑• Sheet❑
e
ro-WHIM-n—AbO
S-L e f t bwA IM
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 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?a OWNERAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APOLIE§rFOWB.;LDING'PERMIT;
as Owner of the subject property
hereby authorize ' ` '1 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
�p `C )cif, 5 as Owner/Authorized Agent
hereby declare that the stateAients 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.
S
Print Na
Signat re of Owner/Agent Date
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:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
f 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 Re gistry of Deeds?
NO DON'T KNOW v/ 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:
i tof Northampton
ton
�1 u ing Department
1 1 Main Street
oom 100
�- rtha pton, MA 01060
pap10F6��4; �jej ,43 1240 Fax 413-587.1272
�nntta,ni,r },
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
c
SECTION 1-SITE INFORMATION,
Thisgsec#i„
1.1 Property Address:
a A rA-s LA � a
o C r Mc
e
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED`AGENT
2.10 ner of Record:
' I If��,"1 1� 5 ` � �(-)rQ 11C o (Ylc- 0ID6d
rc)Name(P t) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(P t) Current Mailing Address:
Signature Telephone
SECTION 3 -'ESTIMATED CONSTRUCTION'CO5T5
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building c-) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
}
cy) , ") Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 0
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) y _ (�(�,. Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of'Bull ings Date
File#BP-2003-0046
APPLICANT/CONTACT PERSON RODRIGUEZ PEDRO J&
ADDRESS/PHONE 1067 BURTS PIT RD (413)584-5930 Q
PROPERTY LOCATION 1067 BURTS PIT RD
MAP 36 PARCEL 040 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T}peof Construction: ENCLOSE EXISTING CARPORT TO 3 SEASON PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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
Permit from Elm Street Co ion
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
BP-2003-0046
GIs#: COMMONWEALTH OF MASSACHUSETTS
. CITY OF NORTHAMPTON
a
Lot: -001
Permit: B u i I d i ng
Categoa: BUILDING PERMIT
Permit# BP-2003-0046
Project# JS-2003-0119
Est.Cost: $4500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa. ft.): 12501.72 Owner: RODRIGUEZ PEDRO J&
Zoning:URA Applicant: RO D R I G U EZ P E D RO J &
AT. 1067 BURTS PIT RD
Applicant Address: Phone: Insurance:
1067 BURTS PIT RD (413) 584-5930 O
FLORENCEMA01062 ISSUED ON.7115102 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE EXISTING CARPORT TO 3 SEASON
PORCH
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/15/02 0:00:00 178 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo