25C-051 (3) �[1tA1e1p�.
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
t
I, � !
(licensee/permittee)
with a principal place of business/residence at:
0/ aJ--e phone#)<` 6
(street/city/sta&zip)
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 Daze)
! ` I am a sole roprietor general contractor or homeowner(circle one) and have hired
the contractors HsO below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poricy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poiicy Number) (Expiration Date)
(Name of Contractor) (lnsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach ad&docal sheers ifmccnsry to include infncmation pertaining to an ooatrae )
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 hoaxowners who employ person:to do maintemaax,c=wu tioa or repair work on a dwelling of
not atone than throe units in which the honteowaa resides or ou the grour&NWeeaaat thereto are not generally ooasiderod to be
earployers it the worker's ooapemstion Act(GL152,=1(5)),application by a homeowner for a liceme or permit may evidm—the
legal states of an employer under the Wodcer's Compemation Act
I understand that a copy of this statement may be forwarded to the Departm A of lndrssbisl Aexideats'Offioe of Inp r for the
coverage verification and that failure to sewn coverage urrda section 25A of MGL 152 can lead to the im pw oa of airman!peaaltiem
comisting of a fine of up to$1,500.00 and/or impr6omma t of up to one year and dvii penalties is the form of a Stop Work Onda and a
fim of 5100.00 a day against ttt�
s` For dgmtnfttal use only
Permit Number
Lot#
Mao
Sig1kirt of Li ermittee
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No Alterations
NORTHAMPTON, MASS. 19 Additions
Repair
APPLICATION FOR PERMIT TO ALTER
S''j Garage
1. Location ij� ��'n?l� -�-^►�� Lot No.
2. Owner's name JS r a,-,L e-,1 r-*/t A ALAI: Address ue_
3. Builders name Sk_ , ��rt✓ :�zlc c� Address 1 riJ '� c
Mass.Construction Supervisor's License No. / y Ole Expiration Date
4. Addition
5. Alteration 4 4"e c oc c-► W'.\,c Le L)
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost:/3 b 0e.).
The undersigned certifies that the above statements are we to the best of
knowledge and belief.
Signature of responsible apgicant
Remarks
10. Do any signs exist on the property? YES NO
IF YES, describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
11. ALL INFORMATION MAST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This col== to be filled in
by the Bnildiag Dvpartmeat
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L• R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved parking}
# of -Parking spaces
f of Loading Docks
Fill:
{vol-ume -& location}
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DIE: APPLICANT's SIGNATURE (`` --
NOTE: issuanoe of a zoning permit does not relieve an, lioan b en to comply wlttx .ail
zoning requirements and obtain all required permits t card of Health, Conservation
iCommission, Department of Pubiio Works and other plioab a permit granting authorities.
FILE #
ro l
i NOV 1 5 1999
Fi 1 e No
ZONING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant:-66g
Address: S'/ ;M 'J e _Telephone: S,?rS —
2. Owner of Property: �i�^^ er �% da e'.W n-t 7Q Z_
Address: Telephone:
3. Status of Applicant: Owner _L:,::�ontract Purchaser Lessee
Other(explain):
4. Job Location: S07 1. i,4-1 c L N Q,.-
Parcel Id: Zoning Map# 9�L6-- Parcel# District(s):
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property he') ,r ICJ t"k-
6. Description of Proposed Use/Work/Project//Occupation: (Use additional sheets if necessary):
:r°ry, /i./t eC L
/c 6
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 PermitNadance/Finding ever been issued for/on the site?
NO DON'T KNOW L---- 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)
59 LINCOLN AVE BP-2000-0516
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:25C-051 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate-gory: windows replaced BUILDING PERMIT
Permit# BP-2000-0516
Project# JS-2000-0896
Est. Cost:$3600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 12501 .72 Owner: BEDNARZ STANLEY W&MARION F&
Zoning.URB Applicant: John Corbett
AT. 59 LINCOLN AVE
Applicant Address: Phone: Insurance:
56 Dimock St (413)584-5807
LEEDS 01053 ISSUED ON.•11/17199 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL REPLACEMENT WINDOWS
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 11/17/99 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo