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DEPARTMENT QF BUILDrXG INSPECTIONS
212 Main Street ' Municipal Building 4
Northampton, Mass. 010$0
wORNER'S CONTENSATxON INSURANCE AFFIDAVIT
with ap/riincipal place of�(busines :
business/residence at r G
1 C 1 G (phone#) qI3
�— (stieet/city/statr/ap)
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 workng on this job:
(Insurance Company) (Policy Number) (Expiration Date)
am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's cornpesl bon policies:
(Name of Contractor) (Insurance Cornpany/Policy Nnmbcr) (Expiration Date)
(Name of Contracior) (h_'SWamctr Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach w1ditiami attect if neomuy to waude iafo,=h,o pertaining to all 0003raciwa)
( I am a sole proprietor and have no one working for me.
(V�Z am a home owner performing all the work myself.
NOTE-pkaae be asvaro that whilo homeowners who emplay p==to do mairdcamce,oonmuaim or repair work on a daeUkg of
not more than time units in which the homw%mcr r=dcs a on the grounds app mealm thereto uz na guseratly 000si i'md to be
on
employ= da the--i( a axuper Wca A I(GL152,es 1(5)�aWlira,6cn by a homeowner for a ticrose or Pamir may cvidewe the
Legal ctatua of app amployx undartbs Wafcds Compmaation AeL
I uadersUad that a copy of thin aratcc CA may be forwarded to tho Deputcocvs ofIndtuRint Aocid*W Offioe of bs rrzaoae for the
oovaagc vaiScision and that W—W seatte coverages under section 25A of MIGL 152 can kid to the i vosdiou of aimiad penalties
oomisting of a fame of vp W$1,500.04 sndfot impr6omnent of up to one year and civil pmxWcs in the form of a Step Work Order and a
tiro OrSt04.00 a day Isdo t ma
r -fY n,o
For
Permit Number
—
?.
Si9fiabizi of LilPermittce Late .
Dec 28 00 12: 16P
1 P. 6
71
.J Licensed Coustruction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date ~
Signature Telephone
Not Applicable ❑
Comfy Name Registration Number
l
Address Expiration Date
� �I Telephone +
ti�'G�1 1��' �"'t �ry�� ��ItRt`�7 1'�/+►�Al'-��u'��4.....7SMl�lk+�¢e��,�'IIXrI��1'��iM71.� �W1�7�'�������
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 homeowncr 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,Citv of
Northampton Ordinances,StatA and Lo al Zoning Laws a d State of Massachusetts General Laws Annotated.
Homeowner Signature
Dec 28 00 12: 15p
p. 5
r
�:_ x. -•..F!..}.,rz. -L,pnz t.ifC. Y.......z .z Y..'..
New House ❑ Addition ❑ Replacement Windows Alteration(s) W/ Roofing O
Or Doors 0
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other[
Brief Description of Proposed Work: �+� 1 a 'e �� e �� I� d�-
Alteration of existing bedroom Yes_^No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet❑
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
t Mascheck Energy Compliance form attached?
g. Energy Conservation Compliance. ,
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 .
1. Septic Tank City Sewer Private well City water Supply
MV IT;
as Owner of the subject property
hereby authorize __ to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
l Cr60 as Owner/Authorized Agent
hereby declare that the statements and inlfo mation on the foregoing application are true and accurate, to the best of my
knowledge and belief. "
Signed u/��r the ains/ nd penalties of perjury.
700 rX (ro a I n
Print Name `
f�12,10 j
Signature of 0 n / ant Date
Dec 28 00 12: 15p
p. 4
r
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 0d 00
Setbacks Front
Side L: R: L:
Rear
Building Height
Bldg,Square Footage '0�^ %
Open Space Footage l� %
(Lotarca 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 4
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 iocationo _
D. Are t ere any proposed changes to or additions of signs intended for the property?YES _
No
IF YES, describe size, type and location: �v
De,c 28 00 12: 13p
P. 3
thampton
(� ��, di partmen#
2 Main Street =
Room 100 R
NortharrlZo , MAO 1060
L._ phone 413.58.124 Fax 413-587-1272
DEPT G.E;}1LD0gG tt&ECTJO ' �
APP LICATI TER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
MY IN
-+. 4 rte,jrE Ms7
1.1 Property Address:;fir N� k }
p /� ,� �j ka �4rxr �} r, 3 et r
f t o
L 1
•ryxu ',r' ,rf�rt.{ +h.i r,rsr y: `,, a j'rk C ,-i:>_ Yt R:
,
h
2. ner o ecord:
u-st (e-
Name Print) Cu a`lineya
Telephone Signature
212 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
t'1C� SI3.».
Item Estimated Cost(Dollars)to be i�ifiedaJ Lisety
completed b permit a licant
1, Building �) irtl� 'e rrii F
2. Electrical Etttted 74t�I}` t
3. Plumbing 00.0l�0 Permit, e
4. Mechanical(HVAC)
5. Fire Protection
6. Total -(1 + 2+3 +4+5) ftt4.Gk ?bet ;
.. :.,.... � . .:.:; .... ,� �tkarr :Afftcta!
Build�n�,Pirn+t t�Iumber. bate Issued
r
trare
,y
BP-2002-0560
GIS#: COMMONWEALTH OF MASSACHUSETTS
36=114 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cateyorywoodstove BUILDING PERMIT
Permit# BP-2002.0560
Project# JS-2002-0869
Est.Cost: $650.00
Fee: $25.00 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Groin
Lot Size(sq. ft.): 16814.16 Owner: CRONIN MARK A&HILLARY L
Zoning URA Applicant: CRONIN MARK A & HILLARY L
AT. 199 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
199 BROOKSIDE CIR (413) 584-9460 (�
FLORENCEMA01062 ISSUED ON:1213101 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOOD PELLET STOVE
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 12/3/010:00:00 MO $25.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
I
199 BROOKSIDE CIR BP-2002-0560
GIs#; COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 114 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categgry:woodstove BUILDING PERMIT
R=4# BP-2002-0560
ftect# JS-2002-0869
Est.cost:$§50.00
)ee:L25.09 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot sim(sa.ft.): 16814.16 Owner: CRONIN MARK A&HILLARY L
Zoning:URA �_,.j�-�F
A leant: CRONIN MARK A & HILLARY L
AT. BROOKSIDE CIR
Applicant Address: Phone: Insurance:
194 BRC►OKSIDF CIR (4131584-9460 ()
FLORENCEMA01062 ISSUED ON:12131010:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOOD PELLET STOVE
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: hough: House# Foundation:
` Driveway Final:
Final: Final:
Rough Frame::"
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:f 1< 1
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND LA
REGUTIONS.
Certifica f OCCu aC1C Si nature.
Fee Type: Receipt No: ., Date Paid: Check No: Amount:
Building 12/3/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo