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1 PAP MENT OF BUILDING INSPECTIONS
n "rain Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licensee/pezmittee)
with a principal place of business/residence at:
S d 1 iiLt G tc_ >! r
(street/city/statrlap)
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:
(Insurance Company) (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 Con=ctor) (Iruurancze Company/Policy N;:mbear) (E.xpi,ation Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shoed if neocsssry to include information pataining to all ooedradora)
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%vWo homeawnets who employ padoas to do—__T Me construction or tspai work on a d 4cuing of
not more than throe units in which the homeowner r eudes or ca the grounds appurtenant thereto are oot generally coandered to be
employers under the workers compensation Act(GL152,ss 1(5)),application by a homeowvcr for a ficertse or permit may evid=c the
legsl status*fan employer under th a Workees Compamatioa Act
I understand that a copy of this ssatemeed may be Porwruded to tho Departarmd oflndratrial Ao idm&O&oe of lnwrwee for the
coverage verification and that failure to secure coverage tmdor seaioa 25A of MGL 152 can lad to the invositioa of criminal penalties
00nsi2i*of a fine of up to S1,500.00 IMNOr imprisomresri of up to one year and civil peaaftia in the form of a Stop Work Order and a
fitto of 5100.00 a day againA tree
For kiattmearal vie aaly
Permit Number
zj Map# Lot#
gna4xre of LiccnserlPermittee
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. I Tel.No. Alterations
NORTHAMPTON, MASS.— Additions
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' APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location 17-1 C r� �aY_.�.�6 St f` Lr- etc _. Lot No.
2. Owners name Address
3. Builder's name 1 G!6.0y c e- : c a Address S& Ll.,~C !c
Mass.Construction Supervisor's License No. l0 floe)C3 Expiration Date yd e:5
4. Addition
S. Alteration art'- lnz�,ur 6. New 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 +t -
13. Siding house
14. Estimated cost-
The undersigned certifies that the above statements are true to the best of
knowledge and belief.
Signature of responsible applicant
Remarks
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181 CHESTNUT ST BP-2000-0917
GIS#: COMMONWEALTH OF MASSACHUSETTS
,Map:Block: 17C-061 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2000-0917
Proiect# JS-2000-1688
Est.Cost:$1600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 27704.16 Owner: COLLINS THERESA M
Zoning.URA Applicant. John Corbett
AT. 181 CHESTNUT ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 584-5807
LEEDSMA01053 ISSUED ON.•4120100 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 4/20/00 0:00:00 775 $25.00
"'-
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo