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12C-068 (2) e y RT'o 0?� Gtt� of No t1julliptoll 7 - g6 f�asanchnsctta -= o DEPARTMENT OF BUILDI?\'C INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 woMCE,R'S COMPENSATION INSURANCE A ,, AViT (li ccnscclperuv ttrc) with a principal place of business/residence at: (mcet/city/staic�z p) do hereby certify, under the pains and penalties of perjury, :hat ( ) I am an empioyer providing the followine colnpens non coverage for Illy employees woi-k�ng on this job. (Ilzurancc Comp.?my) (Polio Nusnlxr) ( xpirarfon Date) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the cons actors listed below who have the following work&s compensation policies: (Name of Contractor) (Inszira,icc Companr)'/Police; Number) (11xpirnuou Date) (Name of Contra(ztor) (Insurance CompanyiPoiicy N =L,-r) (Expit-ation Date) (Name of Contractor) (Insiranc,, Company/PoLcy Name) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (aaach additioml shed if noc�to iii.lode infcrmstioo pertaining to rill o�) (L4� am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plcsc be awzrc thst whi]o homcow who employ persoas w do m+rTTimincc cocl7VGiioe or repair work oo a d-r-L rig of not morn than throe units in wb ch the Lwmc, wn rmida or on the pounds zppurtcnani tb,d arc oot geocratiy 000mdcad to be employtrs under the veorkalz occupc="�tioa Art(GLI52.a l(5)),apptintion by a homcoaxr for a liccasc cc permit may cvi6—the leg l ctaIIu of an employee under dU Wockcc'&Componsai Aar_ I undi t d Chid a copy of this mo mczai may be forwarded to the Dopertmcui of lo�d Acndeats'Offioo of Lnnu,<noe for the coverage vcrificsima and that Un urc to aaurc covcrngo under sccdon 25A of MOL 152 can Icad to the i 'Positiou ofaimiasl pcaaltics ooasisiing of a fine of up to S 1,500-00 arsdlor imprisoomcni of up to 00-ycu and a-,11 pcOzllica io the form of a Stop W ori;Order and a fim o(:S 100-00 a day aga uA me_ For G & use only Ptr Ilt `um Lx:r —. Sipi�ihtrc of Liccnscc/"Pctmittce CTION 8 -CONSTRUCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone .,.,E.. Not Applicable ❑ Company Name Registration Number Address / Expiration Date Telephone 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. ned 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 S"N 6- e FEB 2 81996 lea L a' �a x LX j a 'S7 0 n T � z a 3 r- Z m Z > Z ^' m Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No.sr�(7-cw46 S7- Alterations `* NORTHAMPTON, MASS. / '' 19���' Additions a APPLICATION FOR PERMIT TO ALTER Repair �— Garage 1. Location I ,VG.0 f-,\V*�) Lot No. 2. Owner's name S©0,�am m i 5 c—1 rl nQ Address 31 hlo�r o1 �Sjc p_c�c P 3. Builder's name "o"r`e---, k--� \f ur fl t:iz-', Address - �� C-cam)e,c-� d,--\P_ /� � Mass.Construction Supervisor's License No. u 61 z� Expiration Date 4. Addition t L r' G.�G��S c jz\,\,k 5. Alteration e u� ���.1C1,c�1rr.. U 6. New Porch 7. Is existing building to be demolished? t`1 b 8. Repair after the fire n a 9. Garage Cl o No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof 13. Siding house 14. Estimated cost �'3 The undersigned certifies that the above statements are true to the best of his, her knowledge and belief. Signature of responsible app icon! Remarks 10. Do any signs exist on the property? YES NO IF YES,describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO IF YES,describe size,type and location: 11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This column to be filled In by the Baildiny Department Required Existing Proposed By Zoning Lot size Frontage Setbacks -frnnt - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg &paved parking) # ,..of Parking Spaces # of Loading Docks Fill: '4volume--& location) 13 . Certification: I hereby certify that the information contained herein _ is true and accurate to the best of my knowledge. DATE: °j�,� �� APPLICANT's SIGNATURE NOTE: lss anoe of as zoning permit does not relieve an appiioanYs u en to oomply with all zoning requirements and obtain all required permits from the Board of Health, Conservation . Commission, Department of Publio Works and other applioable permit granting authorities. FILE # y'e k Fi 1 e No. FEB 2 81996 ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: Address: —7, Telephone: �'� 2. Owner of Property: La Address: Telephone: 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): 4. Job Location: �� _ ,�cf /L `ti X, Parcel Id: Zoning Map# Parcel# r— District(s): (TO BE FILLED IN BY THE BUILDING DEPARTMEN 5. Existing Use of Structure/Property 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): VV— 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files. 8. Has a Special Permit/Vadance/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# 9. 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: (FORM CONTINUES ON OTHER SIDE) FILE # 96-06-80 APPLICANT/CONTACT PERSON: .dye, �� � t' ADDRESS/PHONE: PROPERTY LOCATION: _ _> , -- �, , r MAT— PARCEL: THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM MLED 0111 Fee, Pnid 1Riyild*ng Permit r / i�11'7 2L Additinn to Existing e UP 4 F, THB�OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION- Approved as presented/based 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-Bd of Health Well Water Potability-Bd Health !Permit from Conservation mission L Signature of Building lWector Date NOTE:lssuanoe of a zoning permit does not relieve an applloant's burden to oomply with all zoning requirements and obtain all required permits from the Board of Health. Conservation Comm lots lon. Department of Public), Works and other applioable permit granting authorities. City of Northampton REQUIRED INSPECTIONS e BUILDING DEPARTMENT 2. Struccttugral and Components in Place* 3. Complete Building* No. 101 Office of the Building Inspector Zoning Form No. 960680 Date 2/29/96 Fee $40 Check# 1171 Page, 12C Parcel 68 ,Zone URA/wsP Section 127 ❑ Yes 0 No BUI]LDINGPERMI F-I * Plumbing and Electrical Inspections required THIS CERTIFIES THAT Scott Harlow before Building Inspections haspermissionto remodel bathroom(floor, walls, ceiling, fixtures) . Inspection on Site—Foundations situated on 31 Harold Street - Jon Tammis Lander Inspection of Plumbing—Rough provided that the person accepting this permit shall in every respect Inspection of Plumbing—Finish conform to the terms of the application on file in this office, and to the Gas Inspection provisions of the Statutes and the Ordinances relating to the Construction, Inspection of Wiring—Rough Maintenance and Inspection of Buildings in the City of Northampton. Any violation of any of the terms above noted is an immediate revocation Inspection of Wiring—Finish of this permit.Expires six months from date of issuance,if not started. Building Inspection—Rough Note:A certificate of occupancy will be issued by this office upon return Insulation Inspection of this card signed by the Plumbing,Wiring and Building Inspectors. Building Inspection—Finish Smoke Detectors(Fire Department) Other THIS CARD MUST BE DISPLAYED IN A CONSPICUOUS PLACE ON THE P MIS Certificate of Occupancy wilding Inspector