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25C-081 4�ttM1P�, •��Oa � 6 �lasaacbnartta, DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'a Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, (licensce/permittee} with a principal place of business/residence at: (phone#) (streeticity/statz6dp) 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 of Contractor) (Insurance Company/Policy Number) (E)piration Date) (stiach additional sheet ifnecenary to ieclttde infoc:nauon perta;aiag to all ooattactors) ( ) 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 homeowners who ernploy persons to do maiaten=ce�suction or repair work on a dwelling of not more than throe units in which the homeowner resides or oa the grounds appurtenant tb=w are not generally oowkkmd to be employers under the workees compensation Act(GL152,s 1(5)),application by a homeowner for a license or panel ashy evidence the legs!slaws of an employer under the Worker's Compemation Art I undmshad that a copy of this statement may be far-% r to the Departa cni of lndadrial Accident Office of Iasivaaoe for the coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the ia>posihon of criminal penalties 000sistiag of a fine of up to$1,500.00 and/or finprisonment of up to one year and civil penalties in the form of a Stop Work Order and a fma of 3100.00 a day against ttse For dcpattwwW use mlY Permit Number Mao —Lot of# SiVmkdre of LiccnseelPermittee t` SECTION 8-CbNSTR C't1O SERVICES 1 Licensed Construction Su erv' or: Not Applicable ❑ Name of License Holder C-4, "' 6-2OU,6 License Number V 12 eye I v,041.c4, Address Expi Date w /ZQ!X)V^ Signature Telephone RMIM! "UV-t".1� 7Y� ' Not Applicable ❑ Company Name / Registration Number C2 d�,(Ly/ Address �) Expiration Date Telephone SECTION 10�WORKERS'C"PENSATION IN TIRANCE AFFIDAVIT(M.G.L.c. 152,§..2 C(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 o he building permit. -LSigned 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 w y J C 5- T ©' S Appf igAblej >a New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 4 Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work:_ P ft 1112 r AcC c' � Alteration of existing bedroom Yes o Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes Plans Attached Roll ❑ - Sheet❑ M 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 -4WN,ER AUHQnRIZATION„ ,1"OE,CAMPI.I_TD,.WHIN DYVNI>=RS AGENT'04 CONTRACT R-iAPP E, �c�R e�lll►ipt 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 Qnd as Owner/Authorized Agent hereby declare that the statemen information on the foregoing application are true and accurate, to the best of my knowledge and belief. igned under the pains and penalties of pe 'ury. -/ Print Name (,)4 H od Signature of Owner/Age Date r M 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: -T 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: f of Northampton dij ding Department 2112 Main Street Room 100 U 2 Northampton, MA 01060 a phone-4�- e58 1240 Fax 413 587 1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT ION.1- SITE INFORMATION 1.1 Property Address: �.e y eff 0,M SECTION 2- PROPERTY OWNERSHIP/AUTHOkIZED AGENT 2.1 Owner of Record: ee Name(Print) Current Mailing Address: 4ZJ cam A"b Tu'✓ Telephone Signature 2.2 Authorized Agent: om ���e�r e, v "-;'�k Name(Pri t) Current Mailing Address: Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION''6OS'1 S Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) stlmated Total" Cast of Cc i kruction from fi 3. Plumbing Buildmg,,PermK: ee ` 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) Oheck,Number This S.e ion ar i ffitlal Use Ohl Building Permit'NUmber. Dete_lssuedh Signature: Building Commissl6nerlInspect6r of Suildings Date 321 BRIDGE ST BP-2001-0216 GIS#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 25C-081 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2001-0216 Project# JS-2001-0343 Est.Cost: $5875.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Adam Quenneville 120982 Lot Size(sq.ft.): 15202.44 Owner: ZURAW ROBERT Zoning:URB Applicant: Adam Quennevilie AT. 321 BRIDGE ST Applicant Address: Phone: Insurance: P O BOX 612 (413) 527-8375 Workers Compensation SOUTH HADLEYMA01075 ISSUED ON:8124100 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 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 Tyne: Receipt No: Date Paid: Check No: Amount: Building 8/24/00 0:00:00 1548 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo