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25A-137 (5) w r �IZSEaCIdnSr115 � 0 m DEPARTMENT OF BUILDDIC INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMTENSATION INSURANCE AFFIDAVIT (IicenscrJpermitiec) with a principal place of business/residence at: (phone;#) (strc:rt/ci ty/sta t dzi p) do hereby certify, under the pains and penalties of perjury, 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/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Compary/PoLicy Number) (Expiration Date) (Name of Con=ctor) (Insurance Comp my/Pobcy Number) (Fa-pi-m6on Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sleet ifneccaary to inchxfc information pertniu to an co�radors) O I am a sole proprietor and have no one working for me. �I am a home owner performing a11 the work myself. NOTE:please be aware that while homeowners who employ,per;om to do ma�consuoction or repair work on a dwelling of not more than throo units in which the homeowner resides or on the grounds appurtenant thereto a=not Ecoeza 000eidcrcd to be cmployrrs under the worker's oompcasation Act(GL152,ss 1(5)),application by a homeowner for a Uccsse or permd may evidcmoe the legal ctahrs of an employer under the Worker's Compema u Art I undawxnd that a.copy of this uatemcnt may ba forwarded to tho Dcpa tco a of Industrial A,=dn&Offioo of Irr 1-6 for the coverage verification and that fall=to aeeun coverage under sxtion 25A of MGL 152 can lead to the imposition of criminal penalties coasistmg of a fine of up to S1,500.00 mrWor of up to one year and civil pcaalties in the form of a Stop Work Order and a fine of S 100.00 a day against me. For dcpartmridal uao only / Permit Number (/ Map# Lot 4 r Signature of Licenseelpermitiee e l "' aii ,GrN51`�2Ut+�'�lt SE1iICE 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �� S L.�...i../�c'7rN 004- S4 License �- License Number yO ��It— UP S Address Expiration Date Signature Telephone i:Oft Not Applicable ❑ ,.ZN 3 04 Company Name Registration Number Address Expiration Date Telephone ° G1r 1 KER Ct N$ATWIN �1i URA�VCE A��l�{111•V7� �* .L��}�"IGi ;i�� j 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 .r Iff F• New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: �'in P -'t- IZC �.A.✓�C,C� " ` �`��^"1"�� 0�3�� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - 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 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 E�, oK�►�xa� ��l��vi�►c��Ar�d�t �r ��M»>t+�� w�l�r� � �s 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 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 perju Print Name 2 Ua 0 Aa Signature of Owner/ gent Date 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 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: s 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 SECTION 1 SITEJNFt)RM¢ IdN; 1.1 Property Address: ��"mil�'`A✓ !? �'�r^ a'`r. � s' � # ��'�� 9 „S;ECTfII�IRQ,PER'119f Q +t T, �f3 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone Item Estimated Cost(Dollars)to be = )'_Ia O�Y completed by ermit applicant 1. Building (a) 80,41din't ermit F 2. Electrical sb ted Total�q t,3of C0"'', ructiofwle ' 6. 3. Plumbinguil+rtFnerrnt 4. Mechanical (HVAC) 5. Fire Protection Nut 6. Total =(1 + 2 +3+4+ 5) Ciici 1 if t? ber I"T"Mill I Bu�lci, �Permit NiEier Date Issued' Signetur " Buildtgrrlrr+ iar�erllttspetorvf Butldinps Date 20 GLENWOOD AVE BP-2001-0505 GIs#: COMMONWEALTH OF MASSACHUSETTS " Map:Block:25A- 137 CITY OF NORTHAMPTON Lot:-001 Permit: Buildinq Category:roofing BUILDING PERMIT Permit# BP-2001-0505 Project# JS-2001-0866 Est.Cost:$500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot Size(sq.ft.): 9844.56 Owner. ERVIN ERINN Zoning:URB Applicant. ERV I N ERIN N AT. 20 GLENWOOD AVE Applicant Address: Phone: Insurance: 20 GLENWOOD AVE (413) 586-5370 O NORTHAMPTONMA01060 ISSUED ON:11 116100 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF SOUTH FACE ONLY 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 Sianature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 11/16/00 0:00:00 2184 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo