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17C-074 (4) ft, r Ocl x 60 f l � ' �41 k � 4j F r__ .-...... . . _ _ ��1WfP7, o °g �Z�7 X7� �Cl�`��J�IIl�7�IIII k 9 B �lsanchnartta <9 DEPARTMENT OF BUILWNG INSPECTIONS 212 Main Street ' Municipal Building ,o Northampton, Mass. 01060 y WORKER'S COMPENSAITON 1NSURA_NCE t AAVIT (liceuscrJpemvttee) with a principal place of business/residence at: (5t�tici ty/staler p) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following workers compensation coverage for my employees working on this job. (Lasurance Company) (Policy Number) (Expiration Date) O 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) (Lnsuranc-- Company/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Comnaay/Policy Number) (Expiration Date) (Name of Contractor) (Lnsuranc-- Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comp a- Number) (Expiration Date) (attach additioail thc,=t tfnoccnAry to inchidc iafixmatioa pertaia ng a all a dsadnn) O I am a sole proprietor and have no one working for me. 2�am a home owner performing all the work myself. NOTE:picric be awarr that whilo homcow ocra who anplay parer s w miricl�cornra:tioo a rrpair work on a dwelling of not more than tlit)Do unite in winch the homwwvcr reorder a oa the E uun i appurtcnaaf thereto e c not Scbmily oonsidctcd to be rmployrrs under the veocka's cosiTcrsatico Act(GL152-"1(5)),application by a homcow=far a license cc permit may evidence the legal ctx ue of an omployec underthe Woriroet Compcmation Ad I uadcrtt=d chit a copy of this tut-rzt may be forwcuded to the Dcpartacat of Ioduarrial Aoadrn&Offioe of lu%uweo for the coverage vaificatioa and iliac failure to&==covcrago tinder section 25A of bIGL 152 can lead to tbd impositiOn of criminal pcnalt:cs consisting of a one'of up to S1,500.00 and/or impriso�icrit of up to one yc r and civil pcmttia in the form of a Stop Work Order and a find of S 100.00 1 day against me_ For 6"'tursdal uio Only •. Permit Number Lot 4 Si of Liccnsce/Pcrmittce e SECTION 8;=.;CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder License Number Address Expiration Date Signature Telephone �9 tR Q stered`Fliim IrriprQvement'Contracto'r Y, ,m „.. _ ; Not Applicable �. ,u � s 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. Signed Affidavit Attached Yes....... ❑ No...... ❑ om ®wn��r ;e pion 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 — SECTI PTION OF PROPOSED WORK(check afl aaplicable) New House ❑ Addition ❑ Replacement Windows' Alteration(s) ❑ Roofing ❑ Or Doors 1 Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: PEpk/9cJE ( J V0 C1 r Gci $� rUthrg DG D� Alteration of existing bedroom Yes t.,- No Adding new bedroom Yes �No Attached Narrative❑ Renovating unfinished basement Yes _ No Plans Attached Roll ❑ - Sheet 0 SaIfNewhousea"ndor..'ad"dition"to exist�ng=fiousing,compte"tethefollowing: 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 SECTION 7a; OWNER�ALITHORIZATION - TO BE COMPLETED WHEN OWNERS AG' TbR)CONTRACTOR APPLIES FOR BUILDING PERMIT I, 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. Signature of Owner Date I, as Owner/Authorized Agent hereby declare that the statements 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 7ignatuP6 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&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: V f I y of Northampton 5 at sf Pe f (" Q ilding Department Curb Gu i 12 Main Street SewerlSep to I a Room 100 Wa e11r f va OCT 10 2002 N' rt ampton, MA 01060 T� o Sets of ��E� ��� �a � � _ph(.1 � 3 5 7 1240 Fax 413-587.1 272 PIo 1SIte P ans ��� � Own � t)1r DINC,INSPEL710NS Other Sp,c ' pEPi C, B , APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section,to be.completed by office, 1.1 Propert Address: Map Lot ry Zone Overlay,Distnct Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: , n(0 U 9 4 -- Name(Print) Current Mailing Address: — �6 --- — Telephone �� �' 7���✓ Signature 2.2 Authorized Agent: 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 �o (a) Building Permit Fee 2. Electrical (b) E=stimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4 Mechanical (HVAC) 5. Fire Protection C 6. Total = (1 + 2 + 3 + 4 + 5) Check Number J 6 This Section For Official Use Only Building Permit Number: b 3 Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-0383 APPLICANT/CONTACT PERSON FOURNIER RAYMOND P&CAROLYN D ADDRESS/PHONE 33 GARFIELD AVE (413)584-4575 O PROPERTY LOCATION 33 GARFIELD AVE MAP 17C PARCEL 074 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE WINDOW W/SLIDING DOOR New Construction Non Structural interior renovations Addition to Existiniz Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan iFO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION PRESENTED: pproved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commissi Signature of Bui ing Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. .`> BP-2003-0383 GIS#: COMMONWEALTH OF MASSACHUSETTS 4s774.: CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0383 Project# JS-2003.0647 Est. Cost: $2500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Gropp: Homeowner as Contractor_ Lot Sizee(sa.ft.): 12109.68 Owner: FOURNIER RAYMOND P &CAROLYN D Zoning:URB Applicant: FOURNIER RAYMOND P & CAROLYN D AT: 33 GARFIELD AVE Applicant Address: Phone: Insurance: 33 GARFIELD AVE (413) 584-4575 O FLORENCEMA01062 ISSUED ON.10123102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE WINDOW W/SLIDING DOOR 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 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 10/23/02 0:00:00 3233 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo