25C-055 (3) + f
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DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060 'V
WO R'S COMPENSATTON INSURANCE AFFIDAVIT
�censee/ ti>re
(11 perms )
with a principal place of business/residence at:
W,6 0 (pbone#) ---1(07 4 4'v l-
(street/city/ rip)
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(circle 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) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach oml shod tfn6ocnmy to mchrde information pertaining to all oodradors)
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 homcowne s who employ pemns to do maintenance,suction or repair work on a dwelling of
not nwm than throe units in which the homeowner resides a on the grounds appurteaa tbwdo are not generally coandcred to be
employers under the worker's oration Ad(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal statrts of an employer under the Workeet CooVeosation Act
I underslaad that a Copy Of this statement may be forwarded to the Departmca2 oflodrutrial Aoeidan&Offioe of Insunnoe for the
coverage verification and that failure to Secure covera$o under section 25A of MOL 152 can lead to the inVosihon of aiminal penalties
oomisting of a fine of up to 11,500.00 and/or of up to one year and civil penalties in the form of a Stop Work Order sad a
fm of S 100.00 a day agniust me
For dgp¢tmtMW use only
Permit Number
Lot#
Signature of Licensee/Permittee Date
ECTIQN a-Cl7NSTRUCTI+kN 5ERIIiCES
3.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: c-�'�+ J (D—r4 6
License Number
�w�� �f�11�wvJ7 � oil b 4 Cd 20v2
Address Expiration Daie
Signature Te ephone
�I .`.r .,` .a.... of Applicable ❑
Company Name Registr ti n Number
Address qA Oil G P Expir i n Date
Telephone v
SECTION 10-W QRKERS'CQMPENSATIQN tNStlRANCE.AFFIDAVIT(M.G,L,c. 152, §25C(6))
Workers Compensation Insurance affidavit rpust be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of a 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)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
Sw0ESCRIPTION';OF P S (c #c I a `cable
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
/ Or Doors ❑
Accessory Bldg. ❑ Demolitionl� 10ew Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes 4N'/—No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement —Yes _No
Plans Attached Roll ❑ - Sheet❑
0.
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?
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 B.E'COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR Bl1ILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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.
igned under t e pains and penalties of perjury.
Print N
Signature of Owner/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
A. Has a, Special Permit/Variance/Finding ever been issued for/on the site?
NO V 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 V
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:
a
ampton
I artment
2 Street
I I�, MIAIR n ^,�n(� 00
Nortl1 m , MA 01060
DE N 0Fph0ME11 dF3 0 Fax 413.587-1272
, t
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A ION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: �Thi$se g ,o be #eci t
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✓ � � zap
SECTION 2= AQPERTY OWNE'RSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Vcm
Name(Print) Current Mailing Address:
Teleabone
Signature SZ 7 q�ss
2.2 Authorized Agent:
Dqv� PAZ)
Naryze�{Prin Current Mailing Address. u 10
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
competed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) Check Number ' 55
This Section For Official'Use Onl
Building Perrrmit Number: ll� r 7� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2001-0734
APPLICANT/CONTACT PERSON DEAN PARKER
ADDRESS/PHONE 18 FARMINGTON AVE (413)567-6402
PROPERTY LOCATION 41 LINCOLN AVE
MAP 25C PARCEL 055 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
T_ypeof Construction: DEMO PLASTER CEILINGS&WALLS IN KITCHEN&BATH&INSTALL NEW
SHEETROCK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074693
3 sets of Plans/Plot Plan
THE LLOWING 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
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation fission Permit from CB Architecture 7oittee
Signature o Building Official 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.
r
y
41 LINCOLN AVE BP-2001-0734
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-055 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Categ,ory'Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0734
Project# JS-2001-1383
Est.Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DEAN PARKER 074693
Lot Size(sq.ft.): 16509.24 Owner: MORGAN BARBARA&JANE AULISIO
Zoning URB Applicant. DEAN PARKER
AT. 41 LINCOLN AVE
Applicant Address: Phone: Insurance:
18 FARMINGTON AVE (413) 567-6402
LONGMEADOWMA01 106 ISSUED ON:3121101 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO PLASTER CEILINGS & WALLS IN
KITCHEN & BATH & INSTALL NEW SHEETROCK
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
roll Building 3/21/010:00:00 293 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo