17B-005 i
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17tEERClI ItS[ltE
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CONMENSATION INSURANCE AFFIDAVIT
ff
(licenserJpermittee)
with a principal place of business/residence at:
(phone#)
(streeUci ty/staiehip)
do hereby certify, under the pains and penalties of perJury, that.
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Daze)
( ) 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) (1-risurance Company/Policy Nwnbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Fapiradon Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach add?t coal if ncotau to inchxlc infonm,t oa perta n ng to ell oa�rncion)
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 aware that wtrilc homcowvcra who crnplay priors to do maiusain�caczstR=oa or rr it wuvk on a dwclling of
not ma e than tlure units in wf icfr the houmwnct rrsidcj or oo the p-ou appurtenard thado are cot gcaczlly cocsidcmd to be
caVloyrr:r undcr the wmiccen campc--=tic Act(GL152,s3 1(5)),application by a homcow=for a Gccwc cc p-mif may cvi,m—the
1eg21&atud of an omployoc under tho Wort e,compensation Act
I undastsmd that a copy of this ctatcmcal mey be forwnrdod to tbo Dcpwtnrot of IndiLsbial Aceid neY Ofboc of Inwcwcb for tba
coverage vaification and that fathom to secure oovcnTo under soctioa 25A of MGL 152 can lead to the invositiou of a heal pcnaltica
ooexsistin of a fmc of up to S1,300-00=Woe impris�of up to one ytar and civil pcnaltia in the focm of a Stop Work Order and a
fins of 5100.00 t day tgaiwl me
�r
Cf� � u,o city
/; For dcputmr�al(// permit Number
I,ot#
Signature of Lic=-,ec p e
SECTIO,N`8 �CONSTR�UCTIQN SERVICES =3
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
101 R e . bm "vemeri" =�n r A "; Not Applicable ❑
oa
Company Name Registration Number
Address xpiration Date
TelephoneG' V
,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 affid�
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili(
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act,
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
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 _
SECTION 5 D 5CRIPTIOf��OF�PROPOSED�WORK c� ck��all�a hcable � ;
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
rief 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❑
s Ifi New�tio wand 'dit one#o a itin' :housin com""le eft a #olI.o�r�.n
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
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 ALITHORIZATION -TO BE COMPLETED WHEN
OYIINERSs'AGENT ORTCQNTfA;CTOR APPLIESi FOR;IB,UILDING PERMIT
as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
J'4V —, 7 as Owner/Authorized Agent
hereby declare that the s a ments and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the paind penalties of perjury.
Print Name
Signature of Owner/Agent Date C
f
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:
yj
f----"�� of Northampton
ing Department
I� OCT 2 2 Main Street
Room 100 e
4th Of KlitDiNG�MAFO 0 Olortha pton, MA 01060
"+` '`'''M?1CN e -587-1240 Fax 413-587-1272 Plot/Site
.Ot erg pe ty
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to� 'e-comp lete by office
Nle 1.1 Prropertyy`Addre/ssss:
-! �7 IJnIDC ioty � Lf �t
Zone Overlay Distr�ct��
Elm St. District CB District`
SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Cu ntM ' ingj �s:_
C3V U
At Telephone
If Signature
2.2 Authorized A
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
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) Chuck Number "
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
f
474,4=0 RD,. BP-2002-0359
x 4,
GI #: COMMONWEALTH OF MASSACHUSETTS
'Mao luck: 1'7B-005 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2002-0359
Project# JS-2002-0549
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Edward T Corbett 119488
Lot Size(sa.ft.): 24611 .40 Owner: MORRIS JEFFREY&LAURA LEVINE
Zoning:RR Applicant. Edward T Corbett
AT. 474 BRIDGE RD
Applicant Address: Phone: Insurance:
P 0 Box 6241 (413) 585-0953
HOLYOKEMA01041 ISSUED ON.10 13101 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 800 SO FT ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Deaartment 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 10/3/010:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo