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25C-086 (2) �l aSa AClltr8rlt5 - c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORIKER'S COMPENSATION INSURANCE AFFIDAVIT ;Te 4 L '4� (liier�u=) with a principal place of business/residence at: Sk 14, i,e s kw Die F6 (phone#) ( city/state/aP) do hereby certify, under the pains and penalties of pedu y, that: r O I am an employer providing the following worker's compensation coverage for my employees working on this job: Al (Insurance Company) ((Policy Number) (Fxpiration 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/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E)piration Date) (attach additioml shed if necessary to include informalioa paiaiaiag to all oowra ct m) f I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please her aware tbzt while homeownem who employ perzons to do ambit ain ce,consuuction or fair work ou a dwelling of not awe than throe units is which the hortbownw rich or on the grounds appurteasad the rdo am not generally oo=dcrtd to be employea under the worluees oompeasdion Act(GL152,ts 1(5)),application by a homeowner for a license or p=3h may evidmoe tho legs[clatua of an employer under dhe Wodrees Compensation Act I underhand that a copy of this sutemeat may be focwiuded to the Departs of 1.du3h iel Aoci en&Office of Imru enee for the coverage veifietion and that failure to seclue coverage under section 25A of MGL 152 can lead to the imposiiton of simianl penalfles oomisting of a fine of up to S1,500.00 and/or i apr6omxaL of up to one year and civil pcnatties in the form of a Stop Work Order and a fine of 5100.00 a day against mt Far deparftneatil use only Permit Number D Ma P#_—Lot# Si of Licensee/Permit#ce Date SECTION:$=CI NSTRU.... SE��IiC�S. 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone F � Not Applicable ❑ fi: ASGi'. E_t .�.�.�.�t.. .. .F /D//7 4- Company Name Registration Number /l SST Ju ra 5' �LL<-n /►^ 4-,OIL Address Expiration Date Telephone �Vl SECT1014 10-WORKERS' C0MPENSA 100 INSURANCE AFFIDAVIT(M.G.L.c.152,§2;SC(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. 'gned 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 ROSM13WDE P09-S-91)' 0 Kfghe4 all al2plicable` New House ❑ Addition ❑ Replacement Windows Alteration(s)A Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: S Alteration of existing bedroom Yes '"-1W Adding new bedroom Yes ` No Attached Narrative❑ Renovating unfinished basement Yes Z— N o Plans Attached Roll 0 - 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? 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=-OWNI:a AUTHORIZATION.-TO BE.COMPLETED WH,p t}WNEIRS AGE"', '0 gNTRACTQIR APPLIES-_,F R',BII.LDING PERMIT � � 5' �� 2k �! I, -- / - , as Owner of the subject property hereby authorize i-e ' L to act on my behalf, in al matters rela ' e to work authorized by this building permit application. 9 '` A ot-� s/-,/ Signature of Owner Date I, ' �� , as Owner/Authorized Agent hereby declare t6t the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. igned under the pains an penalties of perjury. Print Nam Signat wner/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 J.. 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 r_ pton D ent 212 Mal et AP�v g Mom orthampton MA 1060 p one Fax 13.587-1272 Ut Of BUILDDON MA 01060 APPLIC TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SEC,TA N I-.-51.tE INFORMATION 1.1 Property Address: ow - �8 SECTIO D N PROPERTX O1rrtNERSHIF�IAUTH©RILE AGENT, i 2.1 Owner of Record: t ame(Print) Current Mailing Address: S�sy- 8�l2 Telephone Signature' ture 2.2 Authorized Agent: .-�-- � � - a . :.,► J/.1=.cis-�- ,/•,.aia s� � �C /D t Z Name(P nt Current Mailing Address: y3-aLk ssa Signa Telephone 31-T , , I T, CT-11400;Ostk Item Estimated Cost(Dollars)to be Offiicw use brily, completed by ermit applicant 1. Building. {a)Building Permit Fee 2. Electrical (b) Estimated Total Cost'of Construction,,from,,,,6 3. Plumbing B,u 141ng Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 +2 + 3 +4+ 5) Check Number Thls 5ectioti.For Official Use.Onl ,0itding.Per mit;Number: Date Issued: Signature: Bull, ii arrimissloner/fnspector of Buildings gate f ULN AVE- BP-2001-0819 n&CIS# COMMONWEALTH OF MASSACHUSETTS Map:Bl CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:windows replaced BUILDING PERMIT Permit# BP-2001-0819 Project# JS-2001-1534 Est.Cost: $1295.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Jeffrey Cranston 101 176 Lot Size(sq 1): 6621 .12 Owner: KARKUT DORIS Zoning.URB Applicant. Jeffrey Cranston AT. 12 LINCOLN AVE Applicant Address: Phone: Insurance: P O Box 307 (413) 268-3504 WILLIAMSBURGMA01096 ISSUED ON:41191010:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 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: C PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ITS RULES AND REGULATIONS. �cupancy Signature: Receipt No: Date Paid: Check No: Amount: 4/19/010:00:00 366 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo s� ��,. 12 LINCOLN AVE BP-2001-0819 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-086 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:windows replaced BUILDING PERMIT Permit# BP-2001-0819 Project# JS-2001-`1534 Est.Cost:$1295.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO. Cont.Class: Contractor: License: Use Group: Jeffrey Cranston 101176 L.-tS' sq ft) 6621.12 Owner: KA&&VT I3C1?I� Zoning:URB Applicant Jeffrey Cranston AT. 12 LINCOLN AVE Applicant Address: Phone: Insurance: P 0 Box 307 (413)268-3504 WILLIAMSBURGMA01096 ISSUED ON:4119101 0:00:40 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 1 POST THIS CARD SO IT IS VISIBLE FROM THE STREET : Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings f i Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: 3 hough: Gil: Insulation: Final: Smoke. Final: THIS PERMIT MAY BE REVOKED BY THE CIT F NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occul2ancy Signature; Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/19/010:00:00 366 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo