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25A-051 (3) $ ' �lxsaarlTttsctis DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION CE AFFIDAVIT f, (Iicenstc/permitiee) with a princip ,place of business/residence at: (phone#) (StrCet/city/Stair/ap) do hereby certify, under the pains and penalties of pedury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insu anm 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 Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) k s (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml short ifnecessary to inclodo information pertaining to all coatrndocz) (�7 am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE-plea be aware that while homcowncra who employ per w=to do+*aides cc construction or repair wort:on a dwelling of not more than throe unit+is which the borneowna•r endea oc on the g vja&apptutcnacrt tbwdo are no(generalty ooandemd to be employers under the vmcker's oompensation Ad(GL152,ss 1(5)�application by a homeowner for a license or permit may evidence the legal lotus of an employer under the Workeet Compomation AcL I undastaad that a copy of this siatemecd may be for ww%ed to tbo Depahtmmt of 1ndzLdrial Aeeidw&OfSoo of Insurwoe for the coverage verification and that failure to accuro coverage under section 25A of MOL 152 can lead to the mVos'h0a of aiminal penal ies oanistiag of a fine of up to$1,500.00 and/or impr6onnent,of up to one year and civil pmaHia in the form of a Stop W ode Order and a find 0(5100.00*day against M For dgnrt o-It"use only t' Permit Number Map# Lot# S' of Li ermitfee e r �STRUb SIRYldS 3.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: /z �" License Number Address Expiration Date Signa ur Telephone IREADUM Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone ECT Yl�SURAN E"AFFIDAVIT(M 152 5 {Q IQN t } 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 Y New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: " Alteration of existing bedroom Yes No Adding new bedr om Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ VIRM 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 c�r� a � >t�� 0 �3�c�1 +!t.ir © wHira _ c_. Ml"ec MO� A$ELKas Owner of the subject property hereby authorize to act on my behalf, in all matters relative work authorized by th building permit application. er Date M'(, (A— MOOS H A$Ec K- , 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. jp6lSigned under the pains and penalties of perjury. w' C'��11E.L 'tea vs HA Print Name Signature of 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 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) A. Has a IX Permit/Variance/Finding ever been issued for/on the site? NO CecX 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 Bo6k 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: r City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587.1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SE T #1 •S1T INFOC,R Ij�t ON`-; 1.1 PropertyAddress: � h 4t c y F iCTl1 PRRTYt�E }CIR/AUT O AGEf "1C 93 .3 ie 2.1 Owner of Record: )t, EL M 0 U k A >Be Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: K10CL 00USNBECK- Name(Print) - Current Mailing Address: Signature Telephone tl fl ibNS"ItiCli Item Estimated Cost(Dollars)to be Off�cel fly „� completed by ermit applicant 1. Building IdInR Permit;1*ee 2. Electrical l (b) Es !d Toot cost.of Ce, cuon, 0 6 ; 3. Plumbing Bulil± lefmlt 3 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 + 2 +3+4+5) , this 5ectlawFor Official t;ls� 3rill �itldicg.Pe t llurrlk :r E site I�sued i uiidl,��o�rr�lssiar�r`�lnslak�cr of:BoE11n�� : pit 46 C 'Y"� BP-2002-0060 GIs#: COMMONWEALTH OF MASSACHUSETTS 25k. CITY OF NORTHAMPTON Lot:-001 Permit: Building Category roofing BUILDING PERMIT Permit# BP-2002-0060 Project# JS-2002-0096 Est.Cost: $10000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: James Roberts 117154 Lot Size(sq.ft.): 40205.88 Owner: MOUSHABECK REALTY INC Zoning:URB Applicant: James Roberts AT: 46 CROSBY ST Applicant Address: Phone: Insurance: 30 Edwards Rd (413)527-6078 WESTHAMPTONMA01027 ISSUED ON:71181010:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 7/18/010:00:00 1327 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo