25A-137 (6) 4(ttAMP�
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<m DEPARTMENT OF BUILDFNG INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORI{ER'S COMPENSATION INSURANCE AFMA AVIT
OJ
(Ii cc nsecl per mi ttc�>
with a principal place of buswe residence t:
AvC: 1��,�4`Nl -ll'IUti ne
w1CyQphor#) S 5
(str�- City/slalr/ap)
do hereby certify, under the pains and penalties of pegury, that.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(La!;=ice Company) (Policy Number) (Expiration Date)
am a sole proprietor, general contractor o circle one) an d have hired
the contractors listed below who have the follow compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insllranc Company/Policy,Number) (Expiration Dale)
(Name of Contractor) (Insurance Comp--ny/Policy Number) (Expiration Date)
(attach additiomi sheet f noDt==y tD include info zru ion patz wins to all o�)
O I am a sole proprietor and have no one working for me.
(�am a home owner performing all the work myself.
NOTE:p(eaac be await that whilo homcowncra who cmplay pazom to do m l r�const7ucuoa or repair work oa a dwelling of
not more than thine units in which tilt homeowner resides or oa the g-oetods zppurtenant thereto arc not gencmay ooancicrcd to be
employes under the wocicces ecmpcasaiioa Act(GL152,ss 1(5)),application by a homcowrxr for a license or pctmi may cvidcnoc the
legal o—, ofan employer underthn Worktes Compensation Act
I undcstaad that a Dopy olth s ctaicmcnt may bo forwarded to the Dcpartaxai of I�dL4ria1 Aacid .&Offioo of Invoxnca for the
! Coverage verificatioa and that failure to s==Coverngo under waioa 25 A of MGL 152 can lead to the imposition of crimimil pcaaWce
oomistizig of a fine of up to S 1,500.00 and/or impriso®cat of up to one year and civil pmsltles in the form of a Stop Work Order and a
find of 5100.00 a day against the
For dgmtmtiYnl use only
� Permit Number
C?Uv Map#i— Lot�
Signature of Liomisee/permittee 7--—��
SECTION$-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' 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...... ❑
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��
C ION 5- DESCRIPTI IN OF PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0"'
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 1ZLfP46VC 4Z_D-rkl� � ��Quiet((_.. lv`{'ST'khml.L DWI
Q At'_A4 e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
Vi � 'n +>�"f
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 FOR 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
_AgA)0 0 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 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
O
Lot Size � Q� S A"v`6
Frontage
Setbacks Front j
Side L: � R: l%'/00 L:
Rear j
Building Height l D I
Bldg.Square Footage S-TPC.DCi` %
Open Space Footage ® %
(Lot area minus bldg&paved 1 8
parking)
#of Parking Spaces c
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO_X 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 v
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:
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-SITE INFORMATION
This section to (itefecfa y fflce
1.1 Property Address:
Map Lot.. . , 1 Un1t
Zone � Aay D ist +et
Elm St. District CB Dittrict
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame(Prrin't)' � Current �f�l ing A
Telephone Ctj
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 (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) ` v Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Bate
20 GLENWOOD AVE BP-2000-0871
GIs#: COMMONWEALTH OF MASSACHUSETTS
``Map:Block:25A- 137 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-0871
Protect# JS-2000-1623
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sg. ft.): 9844.56 Owner: ERVIN ERINN
Zoning. URB Applicant. ERVIN ERIN N
AT. 20 GLENWOOD AVE
Applicant Address: Phone: Insurance:
20 GLENWOOD AVE (413) 586-5370 (1
NORTHAMPTONMA01060 ISSUED ON:4111100 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE GARAGE 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:
OW Building 4/11/00 0:00:00 476 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo