25C-193 -
� B i � �� � �tassacEtttsctts
�PARPAENT OP BUILDNG INSPECTIONS
or, _
2 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensceJpermittee)
with a principal place of business/residence at:
(phone#)
(atreet/city/stafdzip)
do hereby certify, under the pains and penalties of peg'ury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees woridng 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/Polity Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additiocal sheet ifnxmuy to mch)de informirioo pataiuing to all ooatradm)
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 whilo homornwm who employ pasom to do maint__�aac, washvction or repair work on a dwelling of
not wore than throe units in which the homeowner resides cc on the groun6 apputteau t thatto arc not gencrally oomidcred to be
employers under the wvriceez compensation Act(GL152,ss 1(5))�application by a homeowner far a Uccase or permit may evidcuoe the
legal ctatuo of an employer under the W"kees compematioa Act
I understand that a copy of thu statement maybe forwarded to the Dcpertaocnt of Indzrshial AocW-w&Offioc of lnsursnoa for the
oovmge verification wad that failum to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penaWes
eomistzng of a fine of up to 11,500.00 and(or imprisonmerd of up to one year and civil pemltia in the form of a Stop Work Order and a '
firm 0(5100.00 a day against mc.
For depatnumW use cGlY
Permit Number
Map# Lot#
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. "feL No. _`'c Alterations
1
..-NORTHAMPTON, MASS. 19 Additions
' APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Locations Lot No.
_,-2: Owner's name 2' Address19�r/'_
Builder's name Address'? ��
-,-Mass.Constructio; Supervisor's License No. 1 C Expiration Date_.�
4. Addition
r.- Alteration ell
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
x/14. Estimated cosc-
The undersigned certifies that the above statcmcnts are true to the best of his
knowledge and belief.
7 Signaze o responsible appicanl
Remarks -
10. Do any signs exist on the property? YES NO
IF YES, describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT C LIED DUE TO
LACK OF INFORMATION.
ef,ibblumn to be filled in
ZSp hw Building Department
I Required I
Existing Proposed By Zoning
Lot size
Frontage
Setbacks - frnnt
- side L: R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&p6ved Parking!
# of 'Parking Spaces
f of Loading Docks
Fill:
-(volume -& location)
13 . Certification: I hereby certify that the information contained herein
G is true and accurate to the best of my knowledge.
ATE: L — i APPLICANT's SIGNATURE
NOTE: lasumnoe of a� permit does not relieve an pplioant's b rden to comply with-oll
Czoning requirements and obtain all required permits f m the Board of Health. Conservation
ommission, Department of Publio Works and other applionble permit granting authorition.
FILE #
Q s
r '
L
71
999 9
File No
,EPTOF U!
PERMIT APPLICATION (§I0 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
Name of Applicant: �J
Address 44�118--��9��- T elephoner � 7 � 4
Z. Owner of Property:
Address: Telephone:
3. Status of Appiic caner Lessee
Other(explain):
—4 Job Location:
Parcel Id: Zoning Map# '(� Parcel# District(s): _
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5, Existing Use of Structure/Property
L,f- Description of Proposed UseMJV r roject/Occupation: (Use additional sheets if necessary):
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special PermitNadance/Finding ever been issued for/on the site?
NO DON'T KNOW L,-' 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#
9. 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:
(FORM CONTINUES ON OTHER SIDE)
23 HIGHLAND AVE BP-1999-0620
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Blo :,..-° CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category: roofing BUILDING PERMIT
Permit# BP-1999-0620
Project# JS-1999-1181
Est. Cost: $3000.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 5749.92 Owner: ROCKETT ELIZABETH&M FARRICK
Zoning_URC Applicant. James Roberts
AT: 23 HIGHLAND AVE
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTON 01027 ISSUED ON:0110711999
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 Type: Receipt No: Date Paid: Check No: Amount:
Building 01/07/1999 $20.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo