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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVrr
L AIWA
(lic cnsee/permittee)
with a principal place of business/residence at:
ll ��� 4� Sow Mk., Q01S (phone#)
( ty/StaW2ip)
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 working on this job:
-E e wt,o" 6 V', LAS• 60 , W�O 367-5y-o(
(Insurance Co ) (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 additions!sheet Tnocessary to include information pataimng to all ooatn d )
( ) 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 awam that whilo homeowners who employ persons to do main_ _en___ate caosuvdion or repair work on a dwelling of
not more than throe units to which the homeowner resides or on the grounds appurtenant thereto am not grncalky considered to be
employers under the worker's compensation Act(GL152,ss 1(5))�application by a homeowner for a license or permit may evidcooe the
legal status of an employer under the Wodceet Compensation Ad.
I understand that a copy of this statemens may be forwarded to the Dtparbnco2 of Industrial Accidents'Offioe of Insuranoe for the
coverage verification and that failure to seatre covetago under section 25A of MGL 152 can lead to the impos oa of criminal penalties
oomisting of a fine of up to$1,500.00 andlor imprison of up to one year and civil penalties in the form of a Stop Worst Order and a
fum of S 100.00 a day against tae.
For dgnatm="1 use oaty
Permit Number
!iV l 7 2 Map# Lot#
Signature of Licenset'/Pe
SECTION'8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder ors G$l g f 3
License Number
Address ^l Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'CQMP'ENSATIQN,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....... IV' 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
S CT N a- LDESCRIPTIN OF POP ED ec I'a 'cable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
/ Or Doors ❑
Accessory Bldg. ❑ DemolitionC� New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: lusw( �XW "I' C
Alteration of existing bedroom Yes X No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes y!No
Plans Attached Roll ❑ - Sheet❑
y
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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 wner Date
as Owner/Authorized Agent
hereby declare that the stat Vents 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
7 2060
Date
Signature of Owner/Agent
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 4 )o L(�
r
Frontage /a-6
Setbacks Front
Side L: R: 6 L: R:
Rear
Building Height
Bldg.Square Footage 9,v 5 T %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Perm it/Variance/Fin(diinng 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 X
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:
a
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE 0
D
SECTION 1-SITE INFORMATION
1.1 Property Address: 4""
This se dry/ .
Z1 Cwt 1'-e Y^av-&
o off,Z
�X
SECTION!2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone —(
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
62 --— A sal-
Signature Telephone
SECTION ESTIMATED CONSTRUCTION COST5
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building -?!" o o (a) Building Permit Fee
/6 601J-
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) 16 6GU - ao Check Number q
This Section For Official Use Only
Building Permit Number: _ Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2001-0275
APPLICANT/CONTACT PERSON WING CONSTRUCTION INC
ADDRESS/PHONE 116 VALLEY ROAD (413)527-2549
PROPERTY LOCATION 12 MARY JANE LANE
MAP 12C PARCEL 072 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid 3 --`
Tvneof Construction: INSTALL NEW ROOF ON HOUSE&REPLACE EXISTING REGAINING WALLS
W/POURED CONCRETE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 051993
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presentedlbased 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 Commission Permit from CB Architecture Committee
Signature of Buildin fficial 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.
12 MARY JANE LANE BP-2001-0275
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 12C-072 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2001-0275
Project# JS-2001-0446
Est.Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WING CONSTRUCTION INC 051993
Lot size(sq. ft.): 10 7 1 5.76 Owner: MOORE BOB
Zoning URA Applicant. WING CONSTRUCTION INC
AT. 12 MARY JANE LANE
Applicant Address: Phone: Insurance:
116 VALLEY ROAD (413) 527-2549 Workers
Compensation
SOUTHAMPTONMA01073 ISSUED ON:9115100 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL NEW ROOF ON HOUSE & REPLACE
EXISTING REGAINING WALLS W/POURED CONCRETE
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 9/15/00 0:00:00 12355 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo