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25C-214 (2) a 3' R�1PTp goo �• °g �x�' � �����11Y�1�Dtt w g B �lassachttsrtta' r DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKEWS COMPENSATION INSURANCE AFFIDAVIT (licensedpeimittee) with a principal place of business/residence at: (phone#) (street/city/swdzip) 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 worlang on this job: (lusurance Company) (Policy Number) (Expiration Date) am a sole proprietor, general contractor o iig�wor eowner cle one) and have hired the contractors listed below who have the follo e s compensation policies: M.ag,C 81Ar (Name of Contra r) (Insurance Company/Policy Number) (Expiration Date) is (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet tf necessary to awlude mformstion pertaining to all oa tn=tors) ( ) I am a sole proprietor and have no one working for me. f I am a home owner performing all the work myself. !' `NOTE:please be aware tbai whilo homaow n=who employ persons to do mains r a�ooa&vetion or repair work on a dwelling of not more than throe units in which the homoowner resides or on the groin apoutcnad thereto are not generally oomiderod to be employers under the%Ymk es oompensatioa Act(GL152,ss 1(5)),application by a homeeowwr for a license or permit may evidence the legal statue of an employer under the Worker's Compamation Act. I understand that a copy of this statement may be forwarded to the Dcpuuaca2 of Ina-*ial Aoci&a&OfBoe of Imunooa for the coverage verification and that failure to accrue coverage under section 25A of MGL 152 can lead to tba impos6oa of Criminal penalties oonsisting of a fine of up to$1,500.00 and/or of up to one year and civil pemlties is the form of a Stop Work Order and a lino of S 100.00 a day against me, ga dq, sl use Only ��-J, V Ptrmit Number�/ / Map# _I of# .�,� �'S'ipabm o icenswjpermittee SECTION$-CONSTRUCTION SERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ f y E Company Name Registration Number Address Expiration Date Telephone SECTIQN,10-WORKERS'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. igned 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 Zon' Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ' . D SC PJ (�- S fl e to Ii t New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolitiortix New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work:_�� ?�'1`� -t f'—Z�� 2 cO �jh1�0• Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - 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 Via:."OWNER Atr THORIZATIpN -TO B CDIVIPLETED WHIEN 011VNERS.AGENX OR 001#0ACTOR APPLIES OR'BUILDING 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 I, 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 Signature of Owner/A nt `�L 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 L`� 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: r thampton Build i epartment t A 2 0 200121 n Street Roo 100 DEPT OF BUILDING I pto , MA 01060 ¢` "'Iibfi*,411-31587-124 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE,INFORMATION his set�� � try co 1.1 Property Address: , -� - 4t � !w�b 1 J C • Map Lot r#ay � .SECTION 2 P QPERTX;OWNERSHIP�AUTH0 llZFD AGENT 3,. 2.1 Owner of Record: ame(Print) Current Mailing Address: Telephone 1b Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION ESTIMATED 6ONSTkUC.T1OWzC.OSTt.. Item Estimated Cost(Dollars)to be Official Use OnIy completed by ermit applicant 1. Building - (a) Building'Permit Fee 2. Electrical (b) Estimated Totall Gostof Con tructi©n from' 6 3. Plumbing Building permit Fee- 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4 + 5)T Cheep Number This Section For Official Use.Onl' Building Permit dumber: Date Issued: Signature. . building CommissIoner/Inspector of Buildings Data File#BP-2001-0823 APPLICANT/CONTACT PERSON SMITH WARREN J&NORMA J ADDRESS/PHONE 45 NORTH ST (413)584-3996 Q PROPERTY LOCATION 43 NORTH ST MAP 25C PARCEL 214 ZONE URC 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 b '- Tvpeof Construction: DEMOLISH&REMOVE 20 X 9 SHED New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan T/AALOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: ppoved as presented/based 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 Co io Permit from CB Architecture Committee Signature of Building Official 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. a 43 NORTH ST BP-2001-0823 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-214 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:demolition BUILDING PERMIT Permit# BP-2001-0823 Project# JS-2001-1547 Est.Cost: $650.00 Fee:$10.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Groin Lot Size(ss .ft.): 9975.24 Owner: SMITH WARREN J&NORMA J Zoning•URC Applicant: SMITH WARREN J & NORMA J AT. 43 NORTH ST Applicant Address: Phone: Insurance: 45 NORTH ST (413) 584-3996 (� NORTHAMPTONMA01060 ISSUED ON:41251010:00:00 TO PERFORM THE FOLLOWING WORK.-DEMOLISH & REMOVE 20 X 9 SHED 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 4/25/010:00:00 156 $10.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo