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18C-048 (24) a `e, Crx , #ljntun if 6 ass itch usetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORTCER'S COMPENSATION INSURANCE AFFIDAVIT (licensceJpermittee) with a principal place of business/residence at: A / 4. ; ' � p4+ef 4yl' fl1 (phone#) 7 . (strret/city/=d2ip)0/&4/>_--- 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 Cony) (Policy Number) (Expiration Date) ( ) I am a sole propnieto:, 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) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach om1 shoe' ude ifneo=-ry to incl inform m pmuining to all oocdroLdots) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. ` NOTE:pleasa be aware than whilo homoowncrs who employ pasom to do m&mtca n,ce�m strt=oa ar repair work on a dwelling of not more than thtue units is which the bomeowmr raidcs or oo the Vwnd,appurtenant therdo arc not gully oomidered to be employers under the workeez oncapensatioa Act(GL152,ss 1(5)),application try a homeowner fora liceme oc permit may evidcna the legs!statara of an employer under the Wodcor's Campemation ArL I undentaad that a copy of this statemeat may be forwarded to the Depaftaco2 of Indcutrial Ao iden&Ofoc of Insurance for the coverage verification and that failtare to ratan coverago ttnda sectioa 25A of MGL 152 an kid to the imposition of criminal pwaltics oousistiag of a Sme ttf up to S1R500.00 stwor imptisomma3 of up to one year and civil p=dtia in the form of a Stop Work Order and a , tia>'o of 3100.00 a dry a phut me Fa-da1 tsse Doty Permit Number Map# Lot# 8n cure of Licensee/Permittee CONSTRU 8.1 Licensed Construction Supervisor: Not Applicable ❑ R � Name of License Holder:71111 fyw h4t itv 0 License Number Address Expiration Date 44 / J Signature Telephone 0 6 /3o / Not Applicable ❑ Compa y Name Registration Number e� o s Address Expiratfon Date Telephone ` / 'SECTION 10=WORKERS'COMPENSATION`INSURANCE AFFIDAVIT(M.G L -6: 152, 25 (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...... ❑ 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 persons) 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 C 5 DESO 0 OF PRO b c c I I able KiP I"nu i a1 33h 5 u 3. Ti3 New House ❑ Addition ❑ Replacement Windows Alterations) ` �. Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[[ ] Other [ ] Brief Description of Proposed Work: t r Iv Alteration of existing bedroom Yes No Adding n bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet 0 a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms i c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? i f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No I j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . i I. Septic Tank City Sewer Private well City water Supply tO'fION 7a„ OWNEit.AU THI ft�XA ,4 N Tfl !< LET I~D WHEN QWN+I AIRS,AG NT© ON ItAG7!UR APPLIES p1 ! �14flING PI_RMIT �" ``' � °�ti�`�"� 7u';✓z1�` ��' `� as Owner of the subject property hereby authorize to act on my behalf, in II Ltters relative to work authorized by this building permit application. �( Signature o Ow er V Date I. W as Owne Authorized Age here 0y declare that the s atements and information on the foregoing application are true and accurate, to y knowledge and belief. Signed under the pains and penalties of perjury. Prinf. Signa a of Own gent Date t,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 A. Has a Special ermit/Variance/Finding ever been issued for/on the site? 9 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 Doc ent # 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 4 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: c r Ci orthampton nnnj Bu Department ain Street s 100 Di�T Os BUILDING INSPEfon, MA 01060 �r `?TON,MA 0 phone 2Z 40 Fax 413-587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING j r SECTION 1-SITE'I FORMATION This strctYnn to,b�e comp eted:by office 1.1 Property Address: � � � r 6 • .41 Map lot 11n�t 73-? ►'�i Gr q�' 1'Vt Zone ��e�rly D�srict _ Elm St b�strr SECTION 2. P' QPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 10#4(IJ 01 v1-''f ';Jc:7 /vv✓Z (V v Z Name(Print) '�- J Current Mailing Address: �� ' "'�� Telephoned i nature 2.2 Authorized Agent: 1IL&II" 04ASdM �t,,e C-x� V IVA X// Na a(Print) Current Mailing Address:` Signature -4 Telephone p� SECTION 3•:EST,I MAT,ED CONSTRUCTION COSTS' Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost'of Const ruction"firarn. 6 3. Plumbing Building Permit Fee_ 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4 + 5) Check Number d This.Section for O.fficieiUse°OnN Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2001-0933 APPLICANT/CONTACT PERSON Tom Dawson-Greene ADDRESS/PHONE P O BOX 556 (413)296-4421 PROPERTY LOCATION 737 BRIDGE RD MAP 18C PARCEL 048 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 Vp Typeof Construction: STRIP,PLY&SHINGLE PAVILLION ROOF&SCREEN IN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 013633 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: ! �ApproLved 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 Commission Permit from CB Architecture Committee -"-Z- 4e-Z - -/7 / Signature of Building ial 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. BP-2001-0933 GIS#: COMMONWEALTH OF MASSACHUSETTS :. CITY OF NORTHAMPTON Lot:-001 Permit: Buildin Category:roofing BUILDING PERMIT Permit# BP-2001-0933 Proiect# JS-2001-1679 Est.Cost:$9800.00 Fee:$50.0 0 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor. License: Use Group: Tom Dawson-Greene 013633 Lot Size(sq.ft.): 272685.60 Owner: NORTHAMPTON NURSING HOME INC. Zoning URB Applicant: Tom Dawson-Greene AT. 737 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 556 (413) 296-4421 CHESTERFIELDMA01012 ISSUED ON:5118101 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP,PLY & SHINGLE PAVILLION ROOF & SCREEN IN 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 Sienature• Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/18/010:00:00 6914 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo 737 BRIDGE RD BP-2001-0933 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C-048 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofine BUILDING PERMIT Permit# BP-2001-0933 Project# JS-2001-1679 Est.Cost: $9800.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Tom Dawson-Greene 013633_ Lot Size(sq. ft.): 272655.60 Owner: NORTHAMPTON NURSING HOME INC. Zoning:URB Applicant: Tom Dawson-Greene AT. 737 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 556 (413) 296-4421 CHESTERFIELDMA01012 ISSUED ON.5118101 0:00:00 TOPERFORMTHE FOLLOWING WORK:STRIP,PLY & SHINGLE PAVILLIQJ LRO.OR-& V�-----� SCREEN IN POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings. I i{{, C?if�ilS �U(iiI�Ri�U�Ui1 ;1VH �1ufJU Underground: Service: Meter: Footings: Rough: Rough: House# �� '� tiny T dation: r,Final: Final: � t _ 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 5/18/010:00:00 6914 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo