31B-036 (7) i
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKER'S CO ENSATTON INSURANCE AFFIDAVIT
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(str=t/city/state/ap)
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:
(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/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Attach additional stied ifnece—ry to iach►de information per wining to all ooatrndors)
I am a sole proprietor and have no one worlan g for me.
( ) r am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ pc=m to do m&kdenaaa comiroctioa or repair work on a dwelling of
not more than throe units is which the homeowner resides or on the groin appurtenant thereto ace not generally ooaride ed to be
employtm under the worker's oopsstion Ad(GL152,=1(5))�application by a homeowner fora Gcease oc permit may evideaee tho
legs!status of an employer under the Wmkeet Compensation Act
I undawAmd that a oopy of this uatcment may be fa coded to the Deputn ced of Industrial Accidents'Offioe of Insucoe for the
coverage verifiattion and tlutt failure to arum covemp under section 25A of MGL 152 can lead to the imposition of aiminal penalties
combain of a fine of up to S1,5oo.00 and/or imlrisonmcat of up to one year and civil pet Wes in the form of a Stop Work order and a
fine of 3100.00 a day against me.
For degatatw al uao Doty
Y/Y�U Permit Number
Map# Lot#
of Li ermittee
Si Z
Y
1's-i -=NSTRUCT ON SERVICE
S.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
6 1612,
Address LL Expiration Date
Telephone
SECTICIN 1113-WORKERS COMPENSATION 1NSURANCE"AFFIDA1/IT(MG 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...... ❑
NOG
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
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S- D S RI F P_ 0 ec "
�,.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: i9 ti O —
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 -OWNER AUTHORIZATION-TO Bt;COMP ETED WHEN
OWNERS AGENT OR�ON7RACT AI�PLI S I O,' BUILDING PERMIT
as Owner of the subject property
hereby authorize �.�fs �� � P-D0 to act on
my behalf, in y ,matt�rsajt�v to work authorized by this building permit applicati n.
Signature of Owner Date
I, 10 4--VS&gad!''t to as44mw/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.
Print Name
X'7 a
Signature of4bww/Agent v Date
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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:
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� y of Northampton
2Q� i~30ding.Department
242 Main Street
`'` Room 100
Nord ampton, MA 01060
phone 413.587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
"SECTION 1-SITE INFORMATION
h 5 hiss
1.1 Property Address:
t /� rte► i ��1�L � I ��ia�> � � � � ,
SECTION 2- PROPERTY OWN ERSHIP/°AUTHORIZED.AGENT
2.1 Owner of Record: .
,.
6Z I S -'i9 1 ,6 Ml �y�
Name(Print) Current Mailing Address:
Telephone
Signature — S
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
2 a
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSn
Item Estimated Cost(Dollars)to be Official Use Only,
completed by ermit applicant
1. Building I (a) Building Permit-F. e
2. Electrical (b),Estim ted Total Cost50,
Construction frdm S
3. Plumbing Building Permkfes
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) Check Number
;'this Section F r Official!Use Onl
Building Permit Number: Elate Issued:
Signature:
Building Commissioner/Inspector of,Buildir gs Date
10 MYRTLE ST BP-2001-0221
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 31B-036 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin
Category:roofing BUILDING PERMIT
Permit# BP-2001-0221
Project# JS-2001-0363
Est. Cost: $4931.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq. ft.): 4530.24 Owner: RISTAV RAMONA
Zoning.URC Applicant. DE Sheppard Roofing
AT: 10 MYRTLE ST
Applicant Address: Phone: Insurance:
17 1/2 Briggs (413) 529-0170
EASTHAMPTONMA01027 ISSUED ON:8125100 0:00:00
TO PERFORM THE FOLLOWING WORK:STRI P & 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 8/25/00 0:00:00 1995 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo