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25C-045 (3) Nk • �C1iAMP�. of Paz#lent un � �lasaar[tasrtts m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S ONTENSATTON INSURANCE AFFIDAVIT L � sue✓/,l>6 rd '-� (IicenserJpemuttee} with a principal) place of business/residence at: 84) -f A,04,C ,� ,2 7�4,2,, T6 t (phone#) S-6—e114-7 ( ty/sta&2ip) do�Iam y certify, under the pains and penalties of penury, that-. ( an employer providing the following worker's compensation coverage for my employees worlang on this job: 1i Se e T,Z IWuro.4 -LrvJ C-0 !t/e, J"3/J-- 3a/7?/r ad 16' �G'I'� 1 .2 oU^ Insurance Company) (Policy Number) (Expiration Daze) ( ) 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) (Insur=ance Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparty/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sbxc ifneoens y to inchWe information pertaining to all ooadrad ) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing alt the work myself. NOTE:please be aware that while homeowners who employ peso=to do a intennc,consh=tioa or repair work on a d%vcwmg of not more than throe units in which the homeowner resides or on the grounds gppurteaaat thereto are not gweraity ooaridcmd to be employers under the worke's compensation Act(GLI S2,ss 1(3))�application by a homeowner for a licewe or permit may evidenoe the legal status of an employer under the Workeet Compensation Ad I understsad that a copy of this statement may be forwarded to the Doputmeat of rndudr ial Ao ideu&Office of Irmrsam for the coverage verification and that failure to secure coverage under section 25A of MGL 132 can lead to the impO ioa of criminal penalties consisting of a fine of up to 51,500.00 andlor imFtt how of tip to one year and civil penalties is the form of a Stop Work Order and a firm of 5100.00 a day against tat For depatmm1 use only Permit Number /o c•- d/ Map# Lot# Signature of LicenseeiPernut(ce Date SECI I 1710N,8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: z�Pe W.,tj License Number o-6 ig�W/ Address Expiration Date Signature Telephone V--- 0/- ,r47- S- Not Applicable ❑ Company Name Registration Number 781 (7 /00�g Address Expiration Date Telephone SECTION 10-1N"ORKERS'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. Signed Affidavit Attached Yes....... Pr/ 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 FCi,I 1 ON OF c e ' able New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roof' g ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other [ ] Brief Description of Proposed Work: 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? 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 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 4R GQNTRACTOR APPLIES I~OR BUILDING PERMIT © as Owner of the subject property 61;"hereby authorize � 40 ^� Z_ �'2'� `7 to act on my b alf, in all matters relative to wok authorized by this building permit application. Sign ture of Owner Date �oe,,4-,71 as-Owi,er/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. -41 w,jrJ 15'e_,A9 Print Name Signature of 9wRw/Agent Da 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: e, Q it o thampton Buildi partment JUN 15 200#12 Street om 100 Nor ton MA 01060 DE l+4 PW 240 Fax 413.587.1272 NORTHAMPTONY APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE,INFORMATION This t>w t e01 1.1 o iaffP' 1.1 Property Address: aF Wood 14 0 A y St.Duct 8 Ilistriit SECTION 2- PROPERTY;OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 0/vACk t7l�on N�( int) Currep�/OM�jli Address: (! Telephone Sign ture 2.2 Authorized Agent: p x) z- / j ,e rJ L- Jg IZ f'd � 'I�I �R.l 7 Name(Print) Current Mailing A dress: y/G 7 Signature Telephone SECTION 3 ESTIMATED CQNSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of y— Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4 + 5) � �Q °� Check Number This Section For Official Use Only' Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date a i)BIlpYla BP-2001-1062 14f COMMONWEALTH OF MASSACHUSETTS _, :psi✓ gas CITY OF NORTHAMPTON Lot:-001 Permit: Building Cate og g: vin 1iding BUILDING PERMIT Permit# BP-2001-1062 Proiect# JS-2001-1882 Est.Cost: $8200.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sq.ft.): 15550.92 Owner: CHURCH DWIGHT S JR&ROSEMARY Zoning:URB Applicant: B & R Siding AT: 17 WOODBINE AVE Applicant Address: Phone: Insurance: 781 Bridge Rd (413) 586-4167 Workers Comnpensation NORTHAMPTONMA01060 ISSUED ON:6118101 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING 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 6/18/010:00:00 17712 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo