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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Iicenseclpermittee}
with a principal place of business/residence at:
✓'/,I 0(6C 2,--(phone#)
city/sWdzip)
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 worlang on this job:
-(Insurance Company) (Policx 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/Policy Numbcr) (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 ' oa"sheet Tnecessuy to wAude mformuion pertaining to all ooatmr n)
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 whilc homeowners who employ pc=m to do,n.;,dcn=cc contraction or repair wort;on a dwelliag of
not more than three units is which the homeowner sides oc on the grounds appurtenant thereto arc not generally eoosida d to be
employers under the workees oompeasation Act(GL152,ss 1(5)),application by a homeowwr fora license or permit may evidence tho
legal datua of an employer under the Workeet Compematioa Act
I understand that a copy of this statemeat may be forwarded to the Deputmcot of Industrial A=&G&office of Iunuanoe for the
coverage verification and that failure to secure coveraga under section 25A of MGL 152 can lead to the imposition of criminal peaaltica
oomisting of a Sne of up to$1,500.00 anNorfinprbomment of up to one year sad dvil peaaltia is the form of a Stop Work order and a '
find of S 100.00 a day against mo.
f, For deputaxaW Um C(11Y
Pe;initNumber
Lot#
Of LicenSmip rmittce
.PIM
x
8.1 Licensed Construction S ervi or: Not Applicable ❑
Name of License Holder
License Number
r wev i A k),*-,/X'�Y;,�4'
Ad&ss,--"7 Expiration DaLfe
n re 11 Telephone
' r r
Not Applicable ❑
Company Name Registration Number
Address Expi atio Date
Telephone �S
.pry M -au"i,
kNSU3 .�4 a s
1_ '152,Af TOT ' 1RCE ` iCA1IT M G' MNSAI �2C(6jj
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....... 93' No...... ❑
mu
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
yea: R
,,gyp Xs'• '�w
M111 1 IS
02 MMEII
• 1
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other[ ]
Brief Description of Proposed Work: 141 hT t 6- C se
Alteration of existing bedroom Yes No Adding n bedroom Yes No
Attached Narrative[I ,Renovati g 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?
h. 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 andZoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
I, t
7 ,1 It T t.f ' L o;7 C' AI , as Owner of the subject property
hereby authorize ers r, t/ to act on
my behalf, in all matt relative to work authorize by this it ing permit application. /o
/
Signat a of Owner Date
I, c , as Owner/Authorized Agent
hereby clarJfhat tlie sta ements d information on the foregoing application are true and accurate,to the best of my
knowledge and belief.
Signed r the pains and penal ies of perjury.
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Print Na
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Signat e o ner/Agent Date
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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:
i t {
1
11'� 7177
,7 u t City''pf',N rthampton
Building` epartment
• i ' cu02 2 00 in SOtOreet
Nort pt , MA 01060
phpna�4hta� -124 Fax 413-587-1272
01, 6u
APPLICATION TO CONSTRUCT, ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ry 'ff 6 3�1b t 3£,{u� �3I CL @' 33 cR
Ui��l>F��RMAT,�t�N ,
1.1 Property Address: M iy
$ECT1�N 2 P120�ERfY OWNERSHIP/AUTHORIZED AGENT
_ ROO
2.1 Owner of Record:
t,;e Ily I-owerl 7 jl�r 5L, r �
Name(Print) Current Mailing Address: r
CC:v. (PLC Jj Liu�✓ Telephone
Signatuk
2.2 ALLthorized A ent: /
Name ) Current Mailing Address:
o
Sign ure Telephone
s
701-11 &Viii
Item Estimated Cost(Dollars)to be f��al tJ r Oqv,
m feted by ermit applicant
00-1
+
1. Building
�1 l.`ld � �
x
2. Electrical ������' .: ����es�a� ,£ i;�k5`3��
3. Plumbing ulildin gPrmi#F��,,�
4. Mechanical (HVAC) '' �` x
7i so
5. Fire Protection 5,
s �h§ s £ mPxy� 3l1 x k rsa
6. Total =(1 +2 +3 +4+ 5) �!Ch �
, 3 tam` aFA
VQ
81}c � 'Sr ?k4 u ]
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174 NORTH ST BP-2003-0268
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0268
Project# JS-2003-0468
Est. Cost: $6540.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C & T Construction 116981
Lot Size(sa. ft.): 11891.88 Owner: WALDRON ELIZABETH C
Zoning:URB Applicant: C & T Construction
AT: 174 NORTH ST
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON.9118102 0:00:00
TO PERFORM THE FOLLOWING WORK:I N STALL S I D I N G
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 9/18/02 0:00:00 3016 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo