25C-045 (2) t
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DEPARTMENT OF BUILMNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INS—U-RANCE AFFIDAVIT
_ (iic�nsee/permittee)
with a principal place of business/residence at:
44 lye:(phone#) ,--;'
(6trCeU6ty/nalrhip)
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 a sole proprietor, general contractor or homeowner (cisele 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) (Expiraton Date)
(Name of Contractor) (Inswance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiomh sheet ifn6ccsssry to ine}ucle infvrmstion pertaining to ell omit=tors)
I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:please Ix awatc that while homcowrxrs who c=ploy perraas to do mxiatcam1cr c�uction or rcpairwork on a dwelling of
not more than throe units is which the homeowner resides or oa the grounds appid=ani therdo arc not generally coandered to be
employers under the worker's.onmp=s4oa Act(GL152,zs 1(5)�application by s homeowner for a liana or permd may evidence the
legs!etatua of an employer under tho Workees ConV ou iou Ace.
I understand dmi a copy of this cut—it may be forwarded to the Department of Indsutzid Aoad=&O>hoe of Iasursoae forth'
covaxge vaificatioa and that failure to aecurc cova ago under scdioa M of MOL 152 can lead to the imposition of criminal penalties
ooaustmg of a 5ne of up to S 1,500.00 and/or impr6o=xnt of up to one year and eiva peaaltia in the form of a Stop Work Oc�and a
faro of 5100.00 a day against ma
For d t1f0 only
permit Number
Magi Lot#
Signature of
rr
1
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: // * V �� ' }���' 0 0 6 '? ` 9
-� License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Co many Name _ Registration Number
Address ` Ex iratio Date
! ,
-t-C C) E'C-C- l \l�? Telephone 5— � r!C
SECTI NO 4NORKERS'COMPENSATION INSURANGEAFFIDAVIT°(M 152, §-25G(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
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)familie:
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(
you hire to perform work for you under this permit.
The undersigned"homeownotean ifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, S Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
1
I
•N
u
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other "
Brief Description of Proposed Work: &'!3A f caf 1 F'/O"' U ~� l IIJ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet D
Other
a. Use of bultdirlg: One Family Two Family
b. Number of rooms in-eso 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? 'nt�:/y Fireptaces.or Woodstoves �"n'" Number of each
g. Energy Conservation Compliance. Mascheckrgy Compliance form attached?
�.y
h. Type of construction
i. Is construction within 100 ft. of,yvetfands? ^" Yes No. Is construction withi?t-1,00 yr. floodpiain Yes I
j. Depth of basement a lar floor below finished grade
k. Will build; conform to the Building and Zoning regulations? Yes No .
I. Septic TanW!! City Sewer Private well City water Supply
WU
12 i
as Owner of the subject properr
hereby authorize to act
my behaif, in all matters rel ive to work authorized by this building permit application.
Signature of Owner Date
12 G C 4 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 perjury.
Print Nam
Signature of 0 er/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
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
r 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? NOS 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:
r r ;
rn
of Northampton
? 01
baing Department
212 Main Street
tr1FT BU LDING INSPECTIO Room 100
uAk! roN,Mn otoso orth mpton, MA 01060
phone 413--5S7-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
"SE 'TEINFARIVIATION
�
1.1 Property Address:
F
Zone
SECTION 2 z t'RO;PERTY OWNE2SHIPlAUTtiQRIZED AGENT.
2.1 Owner of Record: _l
r e.4, 4,
a m e rint) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print ! Current Mailing Address:
f �
Signature ` Telephone u
�'�SEC�TION�3 ES'T(MAfi�Q�C�STR�� 'ION�C057S
'»y;-. 7 ,. ,.w,.ic. ., „R.. .NaaNiL Z,,., .-,A rp.__4 ..xsxn,,. •.:' ,: _-
Item Estimated Cost(Dollars)to beOff�elal Use°3Qniy
completed by ermit applicant —
1. Building r-57. a j (a) BuildfingPermiFee _
2. Electrical (b) Estimated Totaf Cost of
construction,frdmi,.6
3. Plumbing Buil'ding'Pe'rmit Ff
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4 + 5) Check Number
ThislSection I"or Official Use,�nt
$ (dgF' rmitlumber
,Date Issued
a
,r
File#BP-2002-0151
APPLICANT/CONTACT PERSON Harvey Messeck
ADDRESS/PHONE 271 Prospect Street (413)584-4460
PROPERTY LOCATION 17 WOODBINE AVE
MAP 25C PARCEL 045 001 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 _
Typeof Construction: REPLACE PORCH FLOOR,RAILINGS&STAIRS
New Construction
Non Structural interior renovations
Addition to Existin$z
Accessory Structure
Building Plans Included•
Owner/Statement or License 006919
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NJ MATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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
Permit from Elm Street Commission
Sign cial Date
at�oBuilding
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
WE3f}D .A�1E BP-2002-0151
GIs#: COMMONWEALTH OF MASSACHUSETTS
25C=045 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0151
Project# JS-2002-0243
Est.Cost: $1800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Harvey Messeck 006919
Lot Size(sg. ft.): 15550.92 Owner: CHURCH DWIGHT S JR&ROSEMARY
Zoning:URB Applicant: Harvey Messeck
AT: 17 WOODBINE AVE
Applicant Address: Phone: Insurance:
271 Prospect Street (413) 584-4460
NORTHAMPTONMA01060 ISSUED ON:819101 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE PORCH FLOOR, RAILINGS & STAIRS
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:
Building 8/9/010:00:00 2513 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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Phone(4 3)5874240,Rai.(413),597-1272
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