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APR 6
DEPT Of BUILDING INS
NORTHAMPTON,MA 01p60
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
' permittee}
with a principal place of busine residence
(phone#) L) O ► ��j
' (street city/statr/• p)
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 o homeowner(circle e) and have hired
:. the contractors listed below who have the following wor e s compensation policies:
R
(Name of Contractor (Insurance Co /Poli Number) (Expiration Date)
(N ) (Insuran mPanY cy
c R&P,
� f (N OO oJ o 24>61
e
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poky Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioazl sees ifn6cenuy to include information prrtaining to all oordra )
( ) 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 tint whi to homeowners who employ pc==to do ma i,,te�con&votion or repair wort;on a dwelling of
not more than three traits is which the honww=resides or oa the grounds appurtenant thacw ace not gene roily ooaiidered to be
employers under the twrkeez oca>pecs4on Act(GL152,a 1(5)�application by a homeowner for a Grease or permit may evidence tho
legal d-, of as employer under the Workers Compensation Ac<
I undexstaad that a copy of this uatemant may ba fmw dad to tho Deparwxod of Industrial A=dm&Offim of Iusuraoce for the
cov=gc verification and that failure to team covetage tinder soctioa 25A of MOL 152 can lead to the imposffi-of eximinat penalties
oomisting of a fine of up to$1,500.00 andfor isnpr6onrocit of up to one year and civil penalties in the form of a Stop Work Order and a
find of S 100.00 a day against mc.
For depVtWoal use Ocay
permit Number
Map# Lot#
Signature of LicenseelPermattee Date
G710N�=CCi�ISTRUCTIOIV SERVIGES
..i Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
UNIMUMM
,, << 4 �EEE,,,e o ' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEO'€14N t#�VORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(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.
ned Affidavit Attached Yes....... ❑ No...... ❑
4111
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 buildine 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
*+
0 'SCk1PTLQN bFiPROPOtt 1R- c k all "cabl
New House ❑ Addition ❑ Replacement Windows Alteration(s),V�, Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolitions New Signs [ ] Deck ] _ Siding[ ] Other
Brief Description of Proposed Work: U%k tM0S4tr X At, 2,J J(AArjr
Alteration of existing bedroom Yes No Adding new bedroom Yes 34 No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
NOW
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: , Number of Bathrooms Davl I"_e
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? /,, {
f. Method of heating?I A r--oil, Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance.. Mascheck Energy Compliance form attached?
Type of construction (Qool
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 I
k, Will building conform to the Building and Zoning regulations? Yes No .
i. Septic Tank City Sew r — Private well City water Supply
SECTION '7a:-OWNER..AUTHORIZATION-TO BE COMPLETED WHEN
t}WNEIR AGENT OR,CONTRACTOR ARPLIES OR BUILDING PERMIT
as Owner of the subject property
hereby authorize Y1 to act on
my behalf, in all mat ive to wor authorized by this ilding 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.
igned under the pains and penalties of perjury.
Print Name
ignature 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:
thampton
1D Buildi partment
j 6 201 i Street
A oom 100
pton MA 01060
DEq it l(' ff- -1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEC'flON 1-SITE INFORMATION
1.1 Property T e� �mPletecl b��e
Mtn r 'IIC1 x
�SY/YCA3�� .J�F � k � `� �'d J t. .,}.,4`` to i. z� 5'_�M'4`M`�.'H.��"'..` �.'•`..
zone O� y�lr
Y
u a
Eim SDt�rict _ �tr
SECTION 2=PROPERTY.OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
ame(Print) Current Mailing Address:
l
Telephone
'gnature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
5ECFlON 3 •ESTIMATFmp CdNST _UCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ®� (a) Building Permit Fee
2. Electrical ) ,5 (b) Estimated Total Cost of
"l Construction frog 6
3. Plumbing . Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 +2 + 3 +4+ 5) 7 Check Number d
his Section For Official Use Only
Building Permit Nubr: Date Issued:
S.igoat4r
Building CQmmissionerlfnspector of Buildings Date
File#BP-2001-0787
APPLICANT/CONTACT PERSON HAAS MATTHEW K&DEBORAH K
ADDRESS/PHONE 55 GRANT AVE (413)584-9303 Q
PROPERTY LOCATION 55 GRANT AVE
MAP 25C PARCEL 099 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 n—
T eof Construction: CONSTRUCT 2ND FLR MASTER BATHROOM WITHIN EXISTING&REPLACE
PORCH ROOF&POSTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FLOWING LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedibased 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 Commission Permit from CB Architecture Committee
Signature of Buildin fficial 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.
i
55 GRANT AVE BP-2001-0787
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:25C-099 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0787
Project# JS-2001-1474
Est.Cost: $10750.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 8319.96 Owner: HAAS MATTHEW K&DEBORAH K
Zoning URB Applicant: HAAS MATTHEW K & DEBORAH K
AT: 55 GRANT AVE
Applicant Address: Phone: Insurance:
55 GRANT AVE (413) 584-9303 ()
NORTHAMPTONMA01060 ISSUED ON:419101 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2ND FLR MASTER BATHROOM
WITHIN EXISTING & REPLACE PORCH ROOF & POSTS
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 4/9/010:00:00 106 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo