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28-021 (6)
��LPTO 4 _ Boo °$ �x l0[ itZM11t�tDlt _. � � �aSSACIIttStlla DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT i (licensec/permitcee} with a principal place of business/residence at: (phone#) , t. (streeticity/stalr/zip) do hereby certify, under the pains and penalties of perjury, that: ,.t 4 ' ( ) I am an employer providing the folloNving worker's compensation coverage for my employees worlang 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) (InsZtrance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml shod ifnocc=uy to induce infvrmarioa pertaiaing to all ooatr d ) XI 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 while homeowner who employ person:to do ma int'+++nce,axisuuctioa or repair work on a dwelling of not more than throe units is which the homeowner resides or oa the grotr appurtenant thereto arc not geoeraily comidaod to be employers under the worker's ocuiperisdion Act(GL152,n 1(5)),application by a homeowner for a lice=or permit may cvidcnoe the legal sta4ra*fan employer under the Wotkoea Compensation Act I undmund that a copy of this zutemew maybe fosvmrded to the Dgmrmhm2 of Iodusfrial A oddeW Off oe of lu9uraooe for the cove ra verification and that failure to secure coverages under section 25A of MOL 152 can lead to the imposition of criminal penalties coasisting of a fine of up to$1,500.00 and/or iraprbonment of up to one year and civil Penalties in the form of a Stop Work Order and a lire of S 100.00 a day against me. gPermit tmCUW use�y Number is�P,tf ` _Lot# Stgnab=of Licensee/Permittee e SECTION`8•CONSTRUdTION SERVICES 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : °` �*t ' v 6 ' €- License Number Address Expiration Date Signature Telephone P:E,; �'. t� 5€ e Not y ' :�.,., `. s � Applli3cab�ple� ❑ Company Name y RegistrationjNumber Address Expiration Telephone SECTION 10-WORKERS' COMPENSATION INSA RANCE Af OID'AVIT(M.G.L. c. 152, 2SC(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 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 O-W bkSCRIPT O PROP v",check I' icable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: �` <; " p" ¢4 `_ f, Y'; giC 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 7a ,O;WNER.AVTHORIZATION -TO,BE COMPLETED WHEN OWNERS AGENt QR CONTRACTOR APPI.,I,ES:FOR,-�'iJILDING PERMIT property as Owner of the sub ro j P p Y hereby authorize `` - `' '' '� /^ to act on my behalf, in all matters relative to work authorized by this building permit application. _ r SigAture of Owne Date mfr '' / +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 and penalties of perjury. F Print Name 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 _t� 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 # ,�1 B. Does the site contain a brook, body of water or wetlands? NO ` DON'T KNOW s 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 City f rthampton APR 2 6 20ffluil Department 2 in Street Ro DEPT Of BUILDING INS 100 m t n, NORTHAMPTON,MA, �D % p MA 01060 -pllul It 1+ 0 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 S"I'T INFORMATION 1.1 Property Address: ft +" i F SECTION I!,_P'ROPERTY OWNERS HIP"/AUTHORIZED AGENT 2.1 Owner of Record: ame(Print) Current,t M iling Address: k" �fI � TelWon6 Signature 2.2 Authorized Agent: f. Name(Print)—- Current Mailing Address. Signature Telephone 5SCTIOI 3 "ESTfMATED C"CIIV5TRtlCTiON C©STS Item Estimated Cost(Dollars)to be C3ffeial"l ISM Qi�ly;:'' completed by ermit applicant 1. Building (a)E '10� Permit Leo. 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I +2 + 3 +4 + 5) Check Number his Section For Official Use".Onl k3uitding;PerrnitNumber Date Issued; Signature." , pector f „ Da" o19ultciiding C lings. ... 690 RYAN RD BP-2001-0840 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:28-021 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofma BUILDING PERMIT Permit# BP-2001-0840 Project# JS-2001-1573 Est.Cost: $1200.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Jack Walton Construction 107687 Lot Size(sq. ft.): 36633.96 Owner: DELISLE DOUGLAS V&LOIS S Zoning: SR Applicant: Jack Walton Construction AT. 690 RYAN RD Applicant Address: Phone: Insurance: 130 County Road (413) 667-3358 HUNTINGTONMA01050-9727 ISSUED ON:41261010:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL DRIP EDGE,SHINGLES & RIDGE VENT 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 Siunature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/26/010:00:00 1959 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo