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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1, . ' .�
with a principal place of business/residence at:
0 0.�� (phone#)
(streetici ty/state/a p)
do hereby certify, under the pains and penalties of pef7ury, that:
O I am an employer providing the following workers 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/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(auach addlldccr l shcct if n6cciury to include information pertaining to al]ooh ors)
a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awart that while homco A-0=who cmptoy persons to do mxzlt�c=aructioa or repair worts on a dwelling of
not mom than thme units in which the homeowner rrsidca or oa the grounds appurtanarrt llaxeto arc not gracmlly ooaridacd to be
employers under the worker's compcns4oa Act(GL152,sa 1(5)),application by a homoow=for a Gccase oc permit may evidence tho
Iegal dams of an employer under the Wocicor's compomaiiou ALA-
I un8cr tand that a copy of this ctatcmrnt may be forwarded to tho Dcpwtmco&of Indusfri al Accidm&Of 5oe of l=rusnco for the
eovemg verification and that fail=to secure coverago under scction 25A of MOL 152 can lead to the imposition of aimhw pc❑alt:es
eomistiag of a fine of up to S1,300.00 and/or imMis�of tip to one year and civil pcmttica in the focm of a stop W oric Order and a
faro of 5100.00 a day ag&inst mo.
For dgmtw�uto Only
Permit Number
1.�✓ 1�fao Lot#
` :-rY Stguature of Licensee/Permittce Date
}�S CST�� �•� ONS3�Rl�,C�'�1b�IV�J�I.i[yY lv����j13'�,4..r��A-'ate.
8 1 Licensed Construction Supervisor: s Not Applicable ❑
Name of License Holder : �''' 0
License Number
y
Address G Expiration Date
Signature Telephone
e e Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
;SE CTION'10 Pfl ERS',CO.MPENSATION 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 affid�
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)familie
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(
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
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SSE ON. � D RI�P'T1 PROPDS
TI cc I �a IicableN r }
3o- wsv, II - a f m , M 91tl1
New House ❑ Addition ❑ Replacemen endows Alteration(s) ❑ Roofing ❑
Or Doors !
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: "" °�'a'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
s fi N.e ho se�� I or. :o to x—StJ' J-O'U§in
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
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
SEC710N lax OWNERilAVTHO (ZATION TO BErCQMPLETED WHEN
6
01ryNERS,AGENT�OR CO�NTRA,TOR APPLLIES�FQRrBUILDING,PER
iW
N
as Owner of the subject proper
hereby authorize h 1��,/ '�''`'' to act
my behalfZall matters r tive to work authorized by this building permit pplicatio .
l O Z .
Si atur o caner 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.
Signed under the pains and penalties of perjury.
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 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 #
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:
l.J $
City ojngrtment
mpton S
i�, �B C JAP! 2 � reet 0 Wa e Jt�t"t9A 0106Q oex 413 587 1272 Plot/Ste Pla s
Ot�he=r��SpR Coto fy!,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION:
1.1 Property Address: This section to be completed.by office
Map ' .r Lot - tltlat`
Zone Overlay pistnct
Elm St District CS District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) —4/2 ;9 Current Mailing Address:
C.. /CJ LL4, Telephone
Signature
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
com feted by ermit applicant
1. Building GCS (a) Building Permit Fee'
2. Electrical (b) Estimated Total Cost of
Construction from 6
3, Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0673
APPLICANT/CONTACT PERSON DA Williams
ADDRESS/PHONE 81 Water St. (413) 586-3139
PROPERTY LOCATION 17 HUBBARD AVE
MAP 25A PARCEL 059 001 ZONE URB
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: REMODEL KITCHEN&BATH,INSTALL REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 014612
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF( IATION 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 Commission
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.
gkYlYur; BP-2002-0673
GIS#: COMMONWEALTH OF MASSACHUSETTS
y � CITY OF NORTHAMPTON
Lot: -001
Permit: B u l l d i ng
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0673
Project# JS-2002-1084
Est.Cost: $25000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DA Williams 014612
Lot Size(ss . ft.): 5227.20 Owner: BOURKE ANDREW
Zoning:URB Applicant: DA Williams
AT. 17 HUBBARD AVE
Applicant Address: Phone: Insurance:
81 Water St (413) 586-3139
LEEDSMA01053 ISSUED ON:1130102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & BATH, I NSTALL
REPLACEMENT WINDOWS
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 1/30/02 0:00:00 5600 $125.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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17 HURBARD AVE BP-2002.0673
GIS#: _ ONWEALTH OF MASSACHUSETTS
Ma - :25A CITY OF NORTHAMPTON
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Permit: Building r
cagy:Non stt et al gi ;eat�vgt{orts BUILDINGI! EMIT
�� �P•2Q4� 7,
? itt, JS-2!02.10$4
Est.C* $25000.!!
Fee:$125.00 PERMISSION IS HEREBY GRANTED TO:
Coast,Class: Contractor: License:
I1 >iP_ DA Williams 014612
Lot Siz sa,fn: 5227.20 Q►+'n , RQ1QM,AMREW;
AlicannA Williams
AT: 1.7 H S8A8D AVE
Atm t Address:, Phone; Insu� ranee.-
81 Water St. (413a S8b-3 39
LEEDSMAo1053 WXo O�v. 40,/�•ao.on
TOPERFO1 ,T EFOZLO ING WORK.-REMODEL KITCHEN BATH, INSTALL
REPLACEMENT WINDOWS
EM THIS S VISIBLE Mo—ft THE STREET-
In for of t'lumbi tg inspe for+ 'Wiriing P P.�' Building Inspector
Underground; Service: Meters
Footings:
Ro ugh:, ' �
a Rou h: /{►;@y House# Foundation:
't ���4 .:
Driveway Final:
Final: zr 6;r Final:
Rough Frame.41K 15 —7-0 P -i
Gas: Fire IDenartment: Fireplace/Chimney:
Rough: ll: Insulation:
Finals t ak • Final: t4K
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Cgrtificatg Of i at re•
Fee e: R cep Nv; Date Paid: Check No: Aftuxit:
Building 1/30/02 0:00:00 5600 $125.00
212 Main S#cet,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo