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Boo 6 B �Tasaxcllnscfta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, (licensee/peTmi��ee} with a principal place of business/residence at: (phone#) (street/city/sta&2/ p) do hereby certify, under the pains and penalties of pemiry, 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 Company/Policy Numbcr) (Expiration Date) R� r (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance;Company/Policy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional shed ifnecenary to include information pertaining to all 000tradors) ( ) 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 homcowncn who employ paso¢s to do maidrnr mnsuuction or tzpair work on a dwelling of not more than throe units is which the homeowner resides or on the grounds appurtenant theato arc not geoeraily considered to be employers under the work oornpe nation Act(GL152,ss 1(5)},application by a homeowner for a license or permit may evidence the legal status of an employer under the Workeez Compeonation AcL I understand that a copy of this thtemeat may be forwarded to tbo Depa tm� of Industrial Aoc&a&Ofoe of Imruance for the ooverxge verification and that failure to&=ire ooverav under section 25A of MGL 152 can lead to the imposition of criminal pmaltiea Consisting of a fine of up to S1,500.00 and/or imprison of tip to one year and civil penalties in the form of a Stop Work Order and a fins of S 100.00 a day against tt>s. For dgmtwal use only Permit Number Map# Lot# ri, Signature of Licensee/Permittee Date SECTION$ "CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone a M,MAIN �� . SEE << Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10r WCIRKERS' 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. igned Affidavit Attached Yes....... ❑ No...... ❑ e�fld1C1 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 o M sachusetts General Laws Annotated. omeowner Signature thg.0,111 applicabil e New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. I/ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No {Plans Attached Roll ❑ - Sheet❑ Y a1.„.. 5Y 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? 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 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FUR BUILDING PERMIT I, 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 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. igned under the pains and penalties of perjury. Print Name Signature o Owner/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 090J Frontage Setbacks Front Side L: R: L:Aai Rear Building Height Bldg.Square Footage /a (� % 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—y/ 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: �I I City of-Northampton Building.moartment !,u AUG 2 4 2W M Street RL40M 00 DEPT OF BUI. s`, e ion MA 01060 l Fax 413-587.1272 fi APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORM ATEON 1.1 Property Address: j This section t be compl t ►flct DS Oo S l.�F. e°r Map {X t lt�i rKJ �r Z0 a Overlay t�Istrlct —� > � Elm St.,,al SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED,AGENT 2.1 Owner of Record: 89'e r /� J f�f��r� qd i-ci-6 Ks r.b (E v ame(Print�G�...!°� � Current Mailing Address: E •� Telephon Signature —C)1 ,1 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 3 00 a- (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of H Construction from 6 3. Plumbing A Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 +2 + 3 +4 + 5) Cheek Number '.......... This Section For Official Use Only wilding Permit Number: . Date Issued: Signature: Building.Commissioner/lnspectar of3uildii7gs Date File#BP-2001-0213 APPLICANT/CONTACT PERSON LAFLEUR CAROLE A&LEONARD R ADDRESS/PHONE 215 BROOKSIDE CIR (413)586-0122 Q PROPERTY LOCATION 215 BROOKSIDE CIR MAP 36 PARCEL 112 ZONE URA 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: ERECT 8 X 12 SHED 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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: 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 Co 'on Permit from CB Architecture Committee 8 2 Zooa Signature of Building (cial 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. 215 BROOKSIDE CIR BP-2001-0213 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 112 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category she BUILDING PERMIT Permit# BP-2001-0213 Project# JS-2001-0340 Est.Cost: $1300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sa.ft.): 16683.48 Owner: LAFLEUR CAROLE A&LEONARD R Zoning:URA Applicant.• LAFLEUR CAROLE A & LEONARD R AT: 215 BROOKSIDE CIR Applicant Address: Phone: Insurance: 215 BROOKSIDE CIR (413) 586-0122 () FLORENCEMA01062 ISSUED ON.8124100 0:00:00 TO PERFORM THE FOLLOWING WORK:E R E C T 8 X 12 S E D 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 8/24/00 0:00:00 1915 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo