17C-014 � � E 3las.nchncrtta —_''
I of
DEPARTMENT OP DUILDP\10 INSPECriot:s
212 Main Strcct ' Municipal DmIding
Northampton, Mass. 01060
WORICER'S CO'MTENSATION INSURANCE Al FIDAVIT
5F= -
(li ceusccJperm)ttcc) —
\,rlth 2 principal place- of business/reside(ce al:
--�" i �..c1tCA_-_Strcer F(�.�c+� tJ�f� Glob 2. 131��;aonc�') S8'{ •9;17"
(sa�t/ci(y/StaicIa p)
do hereby certify, under the pains and penalties of perjury, .hit
( ) I am an employer providing the following workers comnens::jon cove::yt 'or my
eluplovccs wori3'119 on this job.
(fns ----Ic� Coo=—y) (Potic: Nu--abccr)
( ) I a-M a sole proprietor, general cootractor or homeovy-ner (circie 011e) and have hired
the co=actors listed below who have the following workei's policies:
((�Q11)C 0� con�T-!Cio-) (hisu ancc Cotnpan)vPot)c{ Nuinh--:)
(T';mc of Contractor) --- (tnSlfancz Comoa-av/POI.Ic), NumC°i) (Expu Lion Date)
(Name of Com-aelor) Onsuranc; CompaDyfPoUcy Numbu) (Expuzoon Date)
(T'amC of Contractor) R surauc-- Compa- y/Pohcy Numb:r) (L-xpu-auon Datc) .
(snick ocil s' ct rocc�c, o crncUdc inform moo pertainias to.L ccas-..c-0 )
O I am a sole propnetor and have no one worlang for me.
(1�a a home owner performing all the work myself.
NOT:plcsc be cwarc tL, wU,J bcascouacn"bo cmplay pc--soar w So rcpaa"ork on.d..cll---Z or
ant wort t1L.n L-broc Limits in whu the bornoowner r"ido oc oo the p-ouoas app.uten_�tbcc,.o"oo(Gee,-:fly c,=A---c i to be
cniployc-s um'.c Lhc ccvci:ds adios Art(GLI52„n 1(5)�apptic�6m by a bomooav fcr c l, ..�u pens t r y c.-rdcooc the
Icg l n�u<of an esPloye under dan Wo{eels Co�oo Aee.
l undaYtx d did>oopy of Chia tat—may be foe-A-_ded to tbo Dcputmms of Indut�icl Arad..:&OM_or In—r.noo for the
° VCft c VcaiGclioo a.'td th_I L LTr to coctut:tovcn�under Iociioa 25A of MGL 152 can Ictd to the *01A30O of auua t pcc+wcs
comising of a rsoe Of UP to S 1-500.00 XTOOr of up to one yesr tnd asi)pmahio in Le-form of a Stop Work Order and■
ftm of S 100.00 s d_y tFpiaA me
F,Fmit Numbcr
'7'S'0� p::_ Lot .
Si of Liccns"Jpc ttcc
5ET�OIV 8-CONS"TRUCTION SERVICES"
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT�( NQ-WORKERS'"COMPENSATION"loSURANCE AFFIDAVIT tM G L c,`152, §2 C 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....... ❑ 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"certifie� n3 esponsibility for compliance with the State Building Code,City of
Northampton Ordinances, State",and Loca ws and State of Massachusetts General Laws Annotated.
Homeowner Signatur i
R Fti-ITIb Wiig.,IDESC0110TI P PO5 O cue t o licati�le .
�'Mli U..,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding J Other [ ]
Brief Description of Proposed Work: uF ^' V NH1 SycQ`'v5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
fO �' lets he�fO11' vff
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
SEC'SON 7a OVYNER'AUTHORtZATlO?h TO BE�CTOMPLETEp WHEN
OWN) i AEN7`OR OONT ACTOR Appt,iES FOR BI�.I�ING°PERMIT
f
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.
i
Signature of Owner Date
i
I
as Owner/Authorized Agent
her are that the stat nts 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
Signature of Owner/Agent Date
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&payed
parking)
#of Parkin 9 aces
r
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 X 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:
f Northampton
D E C E � V EBI •ng Department
Main Street
Room 100
JUL — 5 2M N pton, MA 01060
phone 411587-1240 Fax 413-587-1272
DEPT OF BUILDING INSPECTIONS . 11 MCI
IKAIVI�10N,MA 010617—
T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
;ECT.I.ON 1-,`SITE,INFORMATION'
_.1 Property Address: e z w
�t 1 L.o-Y—e- S�f e t
IF l vre,vc e M
PECTIN 2 PIOP> RTY OWIERSHIPfAUTHORIZED AGEN
2.1 Owner of Record:
e' i Sir Eck t r
Vame(Prin Current Mailing Address:
P14 NZC , MIW 13jgc
Telephone
Sit( 3 -7 1-j
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIbN ??3= �STIIVIATb CON5TRUCTION COS',S"
Item Estimated Cost(Dollars)to be Official'USe Only
completed by ermit applicant
1. Building a 3 (a) Buildmg Permit Fee
m
�q
2. Electrical aabX' '''Mated T aI Oo t of :
..3„ . .
Co: s rdctlon
Perm�tF
3. Plumbing °Buildln33eej;p3g , 2
d', • � '3 g'
4. Mechanical (HVAC)
5. Fire Protection
6. Total — 1 + 2 +3 +4+ 5 kL
�, ��rr�ber '3� �
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j
T ls:Section:. &,,'D; ffIc�al:Use.Onl
Bi�ll �n 'Nr �er' ]S5lA8CI' ki3 r�3
ah 3
1
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er/�nspactor of `ildmgs, p. 1
3
i
21 LAKE ST BP-2002-0015
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map Block: 17c-014 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Catego :Siding BUILDING PERMIT
Permit# BP-2002-0015
Proiect# JS-1999-1188
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group
Lot Sizes .ft. : 10759.32 Owner: STRACK PAUL F&HEIDI A
Zoning.URB Applicant. ST RA C K PAUL F & HEIDI A
AT. 21 LAKE ST
Applicant Address: Phone: Insurance:
21 LAKE ST
FLORENCEMA01062 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 UPOr .ATION
ANY OF ITS RULES AND REGULATIONS.
Certificate Of Occu anc
Si nature•
Fee Type: Receipt No: Date Paid• Check No• Amount:
Building MONEY ORDER $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo