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B21 W21 a5 - B18 RECYCLE � � D W33-24 - END PANEL __ 7 - - - - - - - - - - UP - §� X04 � �c �asaRrETusrtta r Glio of wart 1jamptall �JIJL � DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street e Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE ATTEDAVIT f, of 53C l n A 0q) -- (li permittee) with a principal place of business/residence at: �I(v oe%k 5 v mce 1 111 010(10 (phone#) (stretii/ci ty/statelzi p) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following workers 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) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (lnsurancz Compauy/Tolicy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (A"ach additioasf sheet ifnercnvuy to include intonation pertaining v)all eootrn osr3) ( ) 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 tvhilc homeowvcra who ernplay persons w do m* tr ,+ was�vciiai or repair work on a d�+clling of not mon than throe units in which the homeowner mid=a on the grouafs appurt,=t thereto arc act gcnrraily 00midcred to be employers under the workez'a compcosation Act(GL152,ss 1(5)),application by a homeowner for a Gcerm or permit may evideaoo the legal status of an employer under the Workeet Compemation AcL I undasiand that a copy of this EWcmcr3 may be forwarded to tho Depertmoed of Indsssir i al Attidrni>Oflioe of Iusuranco for the coverage verification and that failure to sec;=coverngo under section 25A of MGL 152 can lend to tba imposition of criminal Pea cs oomistiag of a fine of up to S1,500.00 and/or imprrso�of up to one year and civil p=allia in the form of a Stop Work Order and a find of 5100.00 a day against tna For h1O odY Permit Number Map# _ _ Lot# Late Si of Li Z 7o tJ T � C -o �• m t�7 Z .� a 3 Polo. -] Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations NORTHAMPTON, MASS. 19 Additions APPLICATION FOR PERMIT TO ALTER Repair /'a � Garage 1. Location L` M� I /�"'t� Lot No. -12- Owner's name `1CSSe \cN1 � z--Kddress L110 �, 'S1 XXBuilder's name -Actfdress Mass.Construction Supervisor's License No. Expiration Date 4. Addition f 5. Alteration �e1 6 - 6. New Porch 7. Is existing building to be demolished? 8. Repair after the fire 9. Garage No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof 13. Siding house L, Estimated cosL- C—zo The undersigned certifies that the above statements are true to the best of his, her knowledge and belief. S gnat a of responsible app icani Remarks Wd W 15 602/�t/ VC -,In C A-)AV Crif� of Nort1jampton 'z �'•o,eV? �H38ACIj118tIlS J DEPARTMENT OF BUILDING INSPECTIONS INSPECT R y�;. 212 Main Street ' Municipal Building Northampton, Mass. 01060 HOMEOWNER LICENSE EXEMPTION _ t (Please Print ) DATE• JOB LOCATI (Map) (Parcel) (Subdivision) HOMEOWNER:- IAM C7YV1 (Name & ddre s T !� (Home Phone) (work Phone) 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. CMR780 Section 109. 1 . 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 p`erformed 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. i 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 BUILDING PERMIT # r 10. Do any signs east 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 MIDST BE COMPLETED, or PERMIT CAN BE DENEED DUE TO LACK OF INFORMATION. VLi- Coin to be f321&d in by the Building Uapaxt--t; Required + Existing Proposed By Zoning Lot size ` CP Af Frontage # 7' 1 Setbacks - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: Lot area minus bldg &paved parking) # -,p'f Parking Spaces i fof Loading Docks Fill: (voZzime--& location) 13 . Certification: I hereby' certify that the information contained herein _ is true and accurate to the best of my knowledge. a. _ APPLICANT's SIGNATURE_ NOTE: tanuanoe of a zoning permit does not relieve an applio s burden to oompty 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. :f ,. FILE # JUL 2 1 M8 File No. i IZE�T t)i- ,- ,. NI"" ._� OTING PERMIT APPLICATION (510 . 2) PLEASE TYPE OR PRINT ALL INFORMATION Name of Applicant: Address: 4(o (f>f k .fit Telephone: �2 Owner of Property: e55 r Address: `(o �K `�� Telephone:_ ���'- eWa 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): L-1r. Job Location: -�� QI jdt ( - Parcel Id: Zoning Map# /` Parcel# District(s):_�� (TO BE FILLED IN BY THE BUILDING DEPARTMENT) Existing Use of Structure/Property 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): C-9 e 7. Attached Plans: Sketch Plan Site Ian 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/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# 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) f 1S l�J L5 Q. L'.r FILE # J POWT/CONTACT PERSON: } _ PROPERTY LOCATION: , MAP PARCEL: ZONE. THIS SECTION FOR-OFFICIAL, USE ONLY, PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE Z()NIDYG FARM FHT T,FT) ()TTT ✓ BuilffinZ Pemit Filled 011t 6 Ty-pi, of Construction- New Cnnstmirtian RemndelinZ Interior Addition to _Fyi-fin2 A�rPCSpr-v �trll('t11T'P THE LOWING ACTION HAS BEEN TAKEN ON THIS AP ICATION': 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 C iss' u Signature ofMilding Inspector Date NOTE:Issuanoa of at zoning permit doer not relieve an applioant's burden to oomply with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commisslon, Department of Publio Works and other applionble pe-rinit granting authorltles. Department: Reference No: BP-1999-0094 ................................... Building, Electrical & Mechanical Permits ......................................................................................... Fee Type: Receipt No: Non structural interior renovations 1ZEC-1999-000160 ......................................................................................... ..... ................................ Paid By: Paid in Full On: Jesse Montgomery TueJul 21,1998 ......................................................................................... ...................................... Received By: Check No: Linda Lapointe 2376 ......................................................................................... ...................................... DEPARTMENT'S COPY Amount: $40.00 ........................... DEPARTMU"NTFILE COPY 46 OAK ST CITY OF NORTHAMPTON BUILDING PERMIT Owner's pulling their own permits or dealing with unregistered contractors for applicable work do not have access to Guaranty Fund(MGL 142A) Issued: Permit No: Inspector: Tracking No.: Fee: 22 Jul, 1998 BP-1999-0094 $40.00 GIS 4: Map Block: Lot: Address: Zoning: Use Group: Lot Size: 1639 17C 002 001 46 OAK ST URB 19602 Contractor: License Type: Insurance: Homeowner as Contractor Address: License No.: Insurance No.: Li!n State: Zip Code: Phone: Proiect No: Category of Work: Const. Class: Cost Estimate: JS-1999-0135 Non structural interior renovati $6,000.00 Description of Work: REMODEL KITCHEN GeoTIVIS@ 1997 Des Lauriers&Associates,Inc. Signature: