28-054 (4) .�
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DEPARTMENT OF BUILDING INSPECTIONS I
` . 212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFF DA.VTT
'censtrJperhuittee}
with a principal,place of business/residence at:
N�R4.4m 7v 6✓1. (phone#)
ort�WCitylStatC/2ip)
do hereby certify, under the pains and penalties of pedury, that:
am an employer providing the following worker's compensation coverage for my
employees worldng on this job:
L z R 1 GY1 r c�G 3i�'X,V U,d O.L f oat`
:t
(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 Con4=y/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioc l shed ifnecesasry to inohode informuion pwwining to all ooatradors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself. r
NOTE:please be aware that while homeowners who employ perz to do,,,a:..rc m ce,suction or repair work on a dwelling of
not more thou three traits is which the homeowner resides or oa the grouads appurtenant thereto arc not generally oonsidered to be
employers under the worker`s oompens4m Ad(GL152,ss 1(5)),application by a homeowner for a lieease or permit may evidenoe the
legal ctanra of an employer under the Workees Compemation Ad.
I understand that a copy of thus rUtemeat may be foewamW to the Department of Indatstrial Accidra&Offioo of Insrrranoa for the
coverage verification and that failure to accrue coverage under section 25A of MGL 152 can lead to the imposition of m iminal Penalties
consisting of a fine of uP to S 000.00 and/or imprisormerd of up to one year and civil peaattits in the form of a Stop Work order and a
firm of 5100.00 a day against me.
For depszmieotal use-Y
Permit Number
o Map# Lot#
Sigaab=of Licensee/pe t Im C/ Date
r b
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: iF'iW�� L' So A,,, y 03L&19 j/J�
License Number
40 4 G-), 'a7- ;10U-"-
Address Expiration Date
Signature Telephone
Not Applicable ❑
/DO 5/'4
Company Name �- Registration Number
Address / Expiration Date
ni i!2 Telephone 4-'l6 7
5EC`fIQN 11RKER 'f �41PENA1�O3NS�II ANCE AFFIIAYIT(lVl 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.
L�kgnecl 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
• � y
New House ❑ Addition ❑ Replacem indows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
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?
00011, 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 0, ER;' tI�IORIXATI, 'C r PLO
1iE:D 'WI�II N
QW t I>l:R 1 tiC16 R .BUIC PI 1 "
`C � C 7'z... as Owner of the subject property
hereby authorize ��-' t�� ^} 1' /� to act on
m a , ' a lative to authorized by this building permit application.
er Date
> as 9+mr/Authorized Agent
hereby declare that the statements and information on the 4oregoing application are true and accurate, to the best of my
knowledge and belief.
igned under the pains and penalties of perjury.
4 �� L � ��� `7'
Print Name
�-- �..-�`� � �c+•-cam U
Signature ofQg9w/Agent I Dat
� 4 a
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
roll- 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:
3;
of Northampton
ding Department
12 Main Street
� o �� LNG Room 100
rpN
�•a1.0.sp� or hampton, MA 01060
phone 4T3 87-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 I'1`E III�RMATl0"
IN
v
1.1 Property Address:
C'
SECTIpN-2
PA 0', ER", Er Af�E1dT
2.1 Owner of Record:
a P ' Curr qt Mailing v ress
Telephone
Sigtratare S '
2 2 Authorized Agent: Q 4
Name(Print) Current Mailing Address:
Signature Telephone
Item Estimated Cost(Dollars)to be Oft icial,Usye On*
completed by ermit applicant
1. Building (a)PA"A'ding Poe iti�e
2. Electrical N Esti`mated 7�C r5st f
Cc�'strtictio�r frr�rti �'
3. Plumbing �dSn :� rmlt
4. Mechanical (HVAC) .�
5. Fire Protection
6. Total =(1 +2 + 3 +4+ 5) 3 5or30 " Oh r tkzer
. ,5 + tr"Of ��1��3� ��dtng Rerrrii Nrrtier Date Issued, '
Signature
t7ate
I,uittlriori#rr�!siurrer/Inspectorfi Btiilcin s ,;
616 RYAN RD BP-2001-0610
GIS#: COMMONWEALTH OF MASSACHUSETTS
'✓Iap:Block:28-054 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: vinyl sidinc BUILDING PERMIT
Permit# BP-2001-0610
Project# JS-2001-1090
Est.Cost: $3430.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq_ft.): 12066.12 Owner: KMETZ JEFFREY&LISA LEFEBVRE
Zoning: SR Applicant: B & R Siding
AT: 616 RYAN RD
Applicant Address: Phone: Insurance:
781 Bridge Rd (413)586-4167 Workers
Compensation
FLORENCEMA01062 ISSUED ON:1 13101 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 Sicnature:
Fee Tvpe: Receipt No: Date Paid: Check No: Amount:
Building 1/3/010:00:00 17474 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo