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25C-119 O�.�ttHMp�O �X7 9 6 JR ass acknselts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ♦ Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDA,Vrr A.) e, (licenser./permittee) with a principaj,place of business/residence at: I 7S/ (phone#) (street/ ty/statehip) do hereby certify, under the pains and penalties of pedury, that: (Z I am an employer providing the following worker's compensation coverage for my employees working on this job: ansurance 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) (Naive of Contractor) (Insurance Company/Policy Number) (Expiradon Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attacY,ad&60ml sheet ifnearsuy to include information pertnining to all oo>traaots) { ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. r NOTE:please be aware that while hoa cownera who employ pawns to do maiateaaar.'q oast iaction or repair work on a dwelling of not more thin three units is which the homeowner resides or oa the grounds app incaud thereto art not gcaa24 considered to be employeta under the worker's o 4oa Act(GL152,s 1(5)),application by a homeowner for a Grease or P-n-a may evidence the legal data of an employer under the Workeet compensation AcL i uoderda d that a copy of this uaicmmt may be formed to tho Department of indus jet Axidmts'Offioe of Iaxwwoe for the coverage vcrificatioa and that failure to seater coverage under section 25A of MGL 152 can lead to the inipasitioa of crimiW penalties oo listing of a fine of up to 11,500.00 anNor of up to one year and civil pmaltia in the form of a Step Work Order and a find o(5100.00 a day against me. For dq=t=3W uao only Permit Number M ao_____----Lot# Signature of Licensc&Permittee e ; t1 1V$ t ONSTR4C1" 1/1C S �3,,. .. 1 Licensed Construction Su ery: / Q Not Applicable ❑ Name of License Holder: oa 6 S�4 License Number Addres Expiration Date ,2 T�fl m o c, ✓Q-- Signature U Telephone )4,7 Not Applicable ❑ Company Name Registration Number 12mo 06-/S7- Addr ss / Expiration Date rV,�.Tf ij t" M 0), /,1,#- Telephone_ S. CTI+D� 10 1CRKEkS'COMP�NS7"11N INSRANt A FIl3AV1'f f;MwG L +�.-152:,1:, C`(�}) 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. L-Rigned Affidavit Attached Yes....... Q� 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 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofi ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[d Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ Rpm 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 OMM OWL- iihis otow, I, O� A V i A) as Owner of the subject property hereby authorize Wj r R R/1,61 V to act on my behalf, in all ma rs relative to work aut rized by this bu'ding permit application. �rJa � 00 Signature caner Date I, ZI— f) (/J i? as 110SWAuthorized Agent hereby declare that the statements and informati9fi on the foregoing application are true and accurate, to the best of my knowledge and belief. 0001k under the pains and penalties of perjury. ,!5-,e,w>) L . 1g9,,410`� Print W4we J 9? /mob a 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ECt1OP 1 5I1'E,iIFffi�iAAT;tt >�+1 � 1.1 Property Address: p ` 4 rz i a �>�c�i©N- PR+t}PI�R`T'Y+��I�RS�r��►ua�H�i��zl�AGENT 2.1 Owner of Record: .76ija P7 4,01,50 ame( rint Curren aijjr18 dddresss: Telephone Signatur S °O'{' 2.2 Authorized Agent: ) , 'Ele IV z Ali Ck Rfl Name(Print) Current Mailing Add ss: J'? 7 ignature Telephone ' sr► Tiu Item Estimated Cost(Dollars)to be UseriY om leted by ermit applicant 1. Building 47 00 (a)�BuE ing Permit 2. Electrical (b) statated Tti , t,tt C00' tructacrrlr:Efiotn. .. 3. Plumbing Buldinerm# e 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 + 3 +4+ 5) 0114 �urhber ii S han Fir Offi lat C nM ulfdi perrtti# i�urtrber ed ate,issu , igraat >akuiitctirrg Corritn[ssPoner/tr#spector of BuaiClirr Date, 27 ELIZABETH ST BP-2001-0543 GIS#: COMMONWEALTH OF MASSACHUSETTS OWN MW.Block:25C- 119 CITY OF NORTHAMPTON Lot:-001 Permit: Buildina Catego!y:vjUl siding BUILDING PERMIT Permit# BP-2001-0543 Proiect# JS-2001-0943 Est.Cost:$9100.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor. License: Use GrooL. B & R Siding 100465 Lot Size(sq.ft.): 3354.12 Owner., SINGLER JOHN JR&RITA Zoning:URB Applicant. B & R Sidinq AT. 27 ELIZABETH ST Applicant Address: Phone: Insurance: 781 Bridize Rd. (413) 586-4167 Workers Compensation FLORENCEMA01062 ISSUED ON.1211100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING POST THIS CARD SO IT IS VISIBLE FROM THE STREET eo*�'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 sianature: Fee Type: Receipt No: Date Paid: Check No: Amount: r'lluilding 12/1/00 0:00:00 17424 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo Nil