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31A-198 (5) �ttAMPT +�04 O s � 6 �cssaciJtrartta DEPARTMENT OF BUILDIIIG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT with a principal place of business/residence at: r _ <�-,47 (Phone#) -1113 5-� e> (str=ULc ty/stald2ip) do hereby certify, under the pains and penalties of perjury, that: L/I am an employer providing the following worker's compensation coverage for my employees working on this job: �6 `be` 4 v 1 , wC, 3i,�' 31 71 y c/o c11_ 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/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional shed ifnocec u to include information pertaining to all 000f' d rs) ( ) 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 wbilo homcowocra who employ perlom to do mxadmaacr'corzstrj=oa or repair work on a dwelling of not more than three units in which the homoow mr midcs or oa the grounds appurtenant tbacto arc oot gcncrally ooasukrtd to be employtrs under the vemictez comp=s400 Act(GL152,ss 1(5)),application by a homeowncr for a Brener cc permit may cvidcnoo the legal status of an employer under the Workoes Compomation Act I understand that a oopy of this ctatcmmt may be forwarded to the Dcpartnsco2 of 1 ia1 Acdd=&Of$oo of[awn ace for the cove age verification aad that failure to secure oovttngo undcr socdoa 25A of MOL 152 can lad to tbo impo on of crimin-s1 Pc &Wes oousisdi of a fmc'of up to 21,500.00 and/or inqxiso=crd of tip to one ym and civil pmaltics in the form of a Stop Wore Order and a firm of 51 00.00 a day agnitut ma. ga&,a,tat use only permit Number s gyp;{ Lot# Signat ue of Liccnsee/Permittee Date Y T SECTION 8-CONS TRU,CTION SERVICES 8.1 Licensed Construction Supervisoorr: Not Applicable ❑ Name of License Holder f lgqilk del(5"Ic O 7 ! �3 License Nu be Address Expir o Date oa Gwr-� V7 '?�7 ?.- Signature Telephone tt Not Applicable ❑ G /.2 o2 J Com an Name Registration Number ��o �1°tiC �� ��� 7 G va Address !, '^ Expiration Date Telephone�/3 S� ?,y7-7J SECTION 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. Signed 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 SECTION�� D > C P a � PR POSED,WOR C lal "app`licable U, ,.x New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: 5�rlA S 0're f— 41-00J Sl_lle_ ,iS l/ /R Sfr Ky4 Alteration of existing bedroom Yes No Adding new bedroom Yes No 301r Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0- Sheet 0 " h e tldit: o i'stin h0ii� in' colin"��1. . a + f�1�,a . 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? h. 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 OWNER�AUTHORIZATION TO BE COMPLETED WHEN OWNN=RS AGENT OR�GONTRACTOR APPLIES''FOR BUILDING.PERMIT y.. . .. ., �. � ... , ,. 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. Signed under the pains nd penalties of perjury. Prirft Name 1-1 e l�Z Signature of Owner/Agent Dat 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: y (� (� Lip V 190 f Northampton i g Department all Main Street ,? APR 1 6 oom 100 NJ) tha pton, MA 01060 240 Fax 413.587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING .SECTION 1 -SITE INFORMATION 1.1 Property Address: his s�ectio a COmpl'et S Zone '¢ Over dyDstriC �` Elm St District - ._CB District SECTION 2 -'PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C kc-r (e— Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: q 3 S 775- Signature Telephone SECTION.3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from: 6° 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) S o © 1 Check Number This Section For Official Use Only B>uilding'Permit-Number. Date Issued: Sgnature Building.Commissioner/Inspector'of B(aildings.. Date; M WASHINGTON AVE BP-2002-0875 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 198 CITY OF NORTHAMPTON Lot:-001 Permit: Bu i I d i nZ Categor. BUILDING PERMIT Permit# BP-2002-0875 Project# JS-2002-1449 Est.Cost: $5300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group RCI ROOFING 074334 Lot Size(ss .ft.): 11238.48 Owner: MICK ANN F&CHARLES Zoning:URB Applicant: RCI ROOFING AT: 54 WASHINGTON AVE Applicant Address: Phone: Insurance: P O BOX 309 (413) 527-4775 Workers Compensation EASTHAMPTONMA01027.0309 ISSUED ON:4117102 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE ROOF POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: 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 4/17/02 0:00:00 523 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo