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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(str>ret/city/stafelap)
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 workers 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 of Contractor) (Insurance Comp my/Policy Number) (Expiration Date)
(attach additional sheet ifnecenary to inchrde information pertaining to all oodmdors)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:ptease be aware that whilo homeowncss who esnploy Pcrsoni to do fftz imma= 0=5tuc:ioe or tcpair work on a dwelling of
not more than throe units is winch die homoowner reside or on the grounds appurtenant iherdo ate not gcocrally ooandemd to be
employers under the worker's oompcnsation Act(GL152,ss 1(5)�application by a homeowner for a license or permit may evidence the
]cgat statue of an employer under the Workoes Compemation Act
I understand that a copy of this siatcmeot may be forwazded to the Dgwt cod of Iodzu .J Acddca&Ofuoc of Innusnca for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal PCUha
oomisting of a fine of up to S1,500.00 and/or impris art of up to one year and civil penslties in the form of a Stop Work Order and a
fino of 5100.00 a day against mo.
For dgmtm l use only
Permit Number
Map# Lot#
Signature of icensee permi e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Compaq Name Registration Number
Address Expiration Date
Telephone
SECTION"10-WORKERS'COMPENSATION.INSURANCE AFFIDAVIT(M.G.L.c. 152,§250(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....... ❑ 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
SECTION:5-EESCRIP?ION OF pRfJR0SED WORK(check allalcable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Pq r Q )lo'.0 !` j?�PLot_C-A�z
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
y,
a. Use of building : One Family T o Family Other
b. Number of rooms in each family unit: Number of Bathro s
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? F6places or Woodstoves Number of each
g. Energy Conservation Compliance. M'�scheck 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 Ofd CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my beha 'n all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 Name
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 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:
! .R
i f Northampton
� ng Department
];� Main Street
� S& � Z 2a � oom 100
DEPT OF SUII r '"INSP §Ia pton, MA 01060 H
N�.
Via. U 1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION',I-SITE INFORMATION
This sections completed bey office
1.1 Property Address: ���4
13 R t'j;Y L' `'Flap dot Ltnit
y >
SECTION'2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
yf,f2 JQdl
Name(Pri t) Current Mailing Address-
Telephone
Signatu a v
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION 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
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) Check Number
This Section For Official Use Only
Building Permit'Number: Date Issued:
Signature:
Building Comm issionerllnspector of Buildings Date
A I
270 BRIDGE ST BP-2001-0254
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-063 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0254
Project# JS-2001-0430
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 12893.76 Owner: YOUNG NORMAN E&MAXINE L
Zoning:URB Applicant. YOUNG NORMAN E & MAXINE L
AT. 270 BRIDGE ST
Applicant Address: Phone: Insurance:
SOUTH MILL RIVER RD
SOUTH DEERFIELDMA01373ISSUED ON:9/12/00 0:00:00
TO PERFORM THE FOLLOWING WORK.REPAIR & REPLACE SLATE ROOF
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 9/12/00 0:00:00 710 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo