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B DEC 21,998 Jlassachaselts
m DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
L M,4RC p F-7C NELLS
(HCensee/permittee)
with a principal place of business/residence at:
82 %Nnu S T/Z r q t M /Y (phone#) �8 -7- 30 l to
utit 1 r 3 (stmet/city/statelap)
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 Company) (Policy Number) (Expiration Date)
( ) I am s�sted general contractor or homeowner(circle one) and have hued
the contract who have the foll owing worker's compensation policies:
bA A( � -MC0 s REL OWE Y41-(,7,g,4L NIt)R boD36 3 --1 - 7 ?
(Name of Contractor) (Insurance Company/Policy Number) (E-xpiration Date)
-'RAV&-L&Z> iC-u 60Ewc bl>9 t' - / '7
(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 additionA sheet ifneonsary to include information pertaining to all ooatmctors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowom who employ peaoas to do mainteaMe construction or repair work on a dwelling of
not atone than throe units is which the homeowner resides or on the grounds appurtenant thereto acs not generally coandered to be
employers under the worker's oompe sdion Act(GL152,vs 1(S)),application by a homeowner for a Game or permit may evidence the
legal ctat=of an employer under the Wadreez Compensation Ad
I understand that a copy of this zW=ncul may be forwarded to the Depacwxat of Industrial Aaida&Oboe of Imucwoe for the
coverage verifiattion and that failure to aeatre coverage under section 25A of MGL 152 an lead to the imposition of criminal penalties
coasbting of a fine of up to$1,500.00 and/or finprisoemxnd of up to one year and civil peaLWes in the form of a Stop Work Order and a
fimo of 5100.00 a day against M
For depanttneaw use only
Permit Number
Map# Lot#
Signature of LicenseelPetmit3ee
70 'v
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. qq Alterations
a NORTHAMPTON, MASS. 06C , ' —191b 2 Additions
APPLICATION FOR PERMIT TO ALTER Repair
4 y Garage
1. Location / Lot No.
2. Owner's name Bob 96-ti, At "`,<PkW - W_ kz..KIt Address
3. Builder's name c6trCan 4' ��bj Address O-q M
Mass.Construction Supervisor's License No. �'� 61)6c9 6 Z� Expiration Date " Zo v y?
4• Addition nn
5. Alteration� Uoa f4c.1� 1�� iD16 l� �U9` I� V4&&-'r �a ovr GfGU-
6. New Porch
7. Is existing building to be demolished? N
8. Repair after the fire
9. Garage—V( b No.of cars Size
10. Method of heating Pie-. 04(OL Ex(5 T/^--,C\
11. Distance to lot lines ILIA
12. Type of roof y1f Llt&
13. Siding house MtAA,
14. Estimated cost- �3&�
t The undersigned certifies that the above statements are we to the best of he
knowledge and belief.
Signature of responsible appicant
Remarks
r�
10. Do any signs exist on the property? YES
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO 1/
IF YES,describe size,type and location:
11 . ALL INFORMATION MUST BE COMPLETED, or .PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This columm to be filled in
by the Building Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear i
Building height �•
Bldg Square footage
%Open Space:
(Lot area minus bldg 44
' '? aakLR r
# of Parking Spaces /A
# 'of Loading Docks N /A
Fill:
_(volume -& location) � 14
13 . Certification: I hereby certify that the information contained herein
�r is true and accurate to the best of my knowledge.
DATE: r APPLICANT's SIGNATURE
NOTE: lsia anoe of a zoning permit does not relieve an applioanVa burden to comply with all
zoning requirements and obtain all required permits from the Board of Health. Conservtation
Commission, Department of Publio Works and other applioable permit granting authorities.
FILE #
File No
i
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT'^ALL INFORMATION
1. Name of Applicant: f'Cc7 S of bun�cS-�J I"tatif t �-n
Address: Telephone: �3
2. Owner of Property: Bob 6ei:' b&A- uSpKC-'f4 'Ar ke it „
Address: UZ,� -�b'f"lR t/r • �"�� Telephone:
3. Status of Applicant: Owner Contract Purchaser—zLessee
Other(explain): I"
4. Job Location: � 3'f71Z br. ;a4 P-car-
Parcel Id: Zoning Map# Parcel#_ 1 District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5, Existing Use of Structure/Property Mkq. / 6���w I J"�(G.S.'-
6. Description of Proposed UseMlork/Project/Occupabon: (Use additional sheets if necessary):
Ga y J�r�' o2h� Floyr -I�D(4 c v n 4 cv 4 d T-�c-<' SP 4w ,
L04113 UV s h zotf o' � D(00 4 in', 64rp�-
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special Permit/Vadance/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#
9. 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:
(FORM CONTINUES ON OTHER SIDE)
e
File#BP-1999-0553
APPLICANT/CONTACT PERSON Barron&Jacobs
ADDRESS/PHONE 241 King St(413)586-8998
PROPERTY LOCATION 82 INDUSTRIAL DR
MAP 25A PARCEL 187 ZONE GI
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit illed out
Fee Paid 402
Type of Construction:
New Construction
Non Structural interior renovations r•
Addition to Existing
Accessory Structure
Build_ing Plans Included:
Owner/Occupant Statement or License# -�
3 sets of Plans/Plot Plan
THE,FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved 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
r of Well Water Potability Board of Health
Permit from Conservation ission
Signature of Building icial 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.
4
Department:
Reference No: BP-1999-0553
...................................
Building, Electrical & Mechanical Permits
........... .............................................................................
Fee Type: Receipt No:
Non structural interior renovations REC-1999-001519
.........................................................................................
..... ................................
Paid By.- Paid in Full On:
Barron & Jacobs Thu Dec 03,1998
.........................................................................................
............ .........................
Received By: Check No:
Linda Lapointe 4085
.........................................................................................
......................................
DEPARTMENT'S COPY Amount: $40.00
---------- ------ ------
DEPA RTM F NT F I I E C 0 11 V 82 INDUSTRIAL DR
CITY OF NORTHAMPTON
BUILDING PERMIT
Owner's pulling their own permits or dealing with unregistered contractors for applicable work do
not have access to Guaranty Fund(MGL 142A)
Issued:
/�� Permit No: Inspector: Tracking No.: Fee:
BP-1999-0553 $40.00
GIS Map Block: Lot: Address: Zoning: Use Group: Lot Size:
9382 82 INDUSTRIAL DR G1 215622
Contractor: License Type: Insurance:
Barron & Jacobs CSL Workers Compensation
Address: License No.: Insurance No.:
241 King St 062475 NWX6003626
City: State: Zip Code: Phone:
NORTHAMPTON MA 01060 (413) 586-8998
Proiect No: Category of Work: Const. Class: Cost Estimate:
JS-1999-1033 Non structural interior renovati $3,860.00
Description of Work:
CONVERT 2ND FLR STORAGE TO OFFICE SPACE
GeoTMS(D 1997 Des Lauriers&Associates,Inc. Signature: