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17C-084 (2) s 'a Grit,, oaf �d�x#I�ttnY}r urn $ ! �iassacFlttsctis DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ` WORKER'S COMPENSATION INSURANCE AFFIDAVIT L pc�J (3 , � (Il cen-sttJper rzv tt ee) with a principal place of business/residence at: /°( I , E-7 C.-4 Q� (phone#) — Z° (st=t/city/staW2ip) 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: (Nance of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Daze) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach a,aditiomt sheet ifneomary to include information peru=mng to an oodmctoas) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:ptmw ba aware tbA vMo homcov,z=who employ pasom to do maiaten-mm construction or npok wait oa a dweIIiog of not 1 o a than tbm unib in which the homeowner rnidm or on the grounds appurt egad tbftdo are cot generally oomidaed to be employam under the wodcn'a coavensation Act(GL152.ss 1(5))�application by a homeowner for a Gomm cc permit may mideow the legal stalua*fan 6WPloya vodartbe W"We Compemation Act I understand that a copy ofthis amat®m3 may be famuded to the Deparbn=d of Inhstrid AeeideW Office of Irmueow for the ooverage vai6cmioa and that failure to swze covaup tinder section 25A of MGL 151 cat tad to the'imposition of mimiud peaaltics comisting of a fine ofup to 51,500.00 and/or kN risoamcnt of up to cm ycar and civil Penalties is the form of a Stop Work Order cad a Eric of 5100.00 a against tae. Fordepartmed+duaomty . C' Pcimtt Ndbbd Map# — Si taf F.uxnsee/Permittce .__ ,•._ ` _ z � a -»� m c °'• t'fl in Z O Z � m ft Zoning Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Alterations NORTHAMPTON, MASS. 19 Additions APPLICa ATION FOR PERMIT TO ALTER Repair Garage 1. Location e Lot N . 2. Owner's name C Address e L 3. Builder's name V C-G"- Address fit-' Mass.Construction Supervisor's License No. (%3 Z 5 qq Expiration Date 00 4. Addition 5. Alteration 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 14. Estimated cost- }" 2 5 c)D -cac) The undersigned certifi s that the above statements are we to the best of his knowledge and belie Signature of responsible app4icon! Remarks 10. Do any signs ebst 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 MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION. This col== to be filled in by the aaildiag Department Required I Existing Proposed By Zoning I Lot size Frontage 5-7 Setbacks tc) - side L:—'5 R: Z` L: �� R: ZG - rearO H 0 Building height , 2� Bldg Square footage %Open Space: (Lot area minus bldg 7, l'1 �' &paved parking) (,� # of Parking spaces f of Loading Docks Fill: {vol-ume--& location) 13 . Certification: I hereby certify that the informa ion contained herein is true and accurate to the best of my knowledg DATE: CG APPLICANT's SIGNATURE NOTE: laeunnoe of a zoning permit does not relieve an apps oanYs burden to oom wit - zoning requirements and obtain ail re wired ply It .4211 q permits from the Board of Health, Conservation Commission, Department of Publio Works and other appliomble permit granting authorities. FILE # L U tlON - 62 UILDING INSPECTIONS 4�fa�J !V!�01060 File No. �- ZONING PERMIT APPLICATION (§10 . 2) PLEASE TYPE OR PRINT ALL INFORMATION 1. Name of Applicant: aul ( , q Address: e, , , Telephone: 3 Sz 2. Owner of Property: v v , Q t Address: e ( ��'�Q1/SIJ S Telephone: Sq 3✓3 � 3. Status of Applicant: Owner Contract Purchaser Lessee Other(explain): 4. Job Location: Parcel Id: Zoning Map# /7C _ Parcel#+�� District(s):_ (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property C, �F"lnv\ 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): 7. Attached Plans: Sketch Plan Site Plan 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) r 87 CHESTNUT ST BP-2000-0647 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-084 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: Windows replace BUILDING PERMIT Permit# BP-2000-0647 Project# JS-2000-1167 Est.Cost: $2500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Paul McCutcheon 062544 Lot Size(sq. ft.): 108 90.00 Owner. MCCUTCHEON PAUL C&MARCHELE I zonin :URB Applicant: Paul McCutcheon AT.• 87 CHESTNUT ST Applicant Address: Phone: Insurance: 87 Chestnut St (413) 584-3352 FLORENCE 01062 ISSUED ON.•1 17100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS/DOWNSTAIRS APARTMENT 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 1/7/00 0:00:00 4381 $25.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Building Commissioner-Anthony Patillo �- ._��_ ,:e _ 87 CHESTNUT ST BP-2000-0647 GIS#: - COMMONWEALTH OF MASSACHUSETTS_ M0:Bluck: 17C-084` CITY OF NORTHAMPTON Lot:-001 Permit: Buitdina ate&orv:windows Mlaced BUILDING PERMIT Permit# 13P-2000-4642 Project# JS-200th-11§7_ Est.Cost:$2500.00 Fee:$25.00 PERMISSIONIS HEREBY GRANTED TO: Const.CIARL Contractor: License: Use Group: Paul McCutcheon 062544 Lot SiMW.&J 10$90.00 Owner: MCCUTC E£}N PAUL C&MARCHELE I Zoning:URB Aoaftant. Patty McCutcheon AT. 87 CHESTNUT ST Amman(Address: Phone: Insurance 87 Chestnut`St (413) 584-3352 FLORENCE 01062 ISSUED QM.1/7/0©6:04:00 TO PERFOM THE FOLLOWING WOJ?K:INSTALL REPLACEMENT WINDOWS/DOWNSTAIRS APARTMENT POST THIS CARD SO IT I5 VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service; Meter: Footings.: Rough: Roughs House# Foundation: Finals; Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Roughs Oil.ra,ation: Final: SLu2m: Final: 19 K THIS PERMIT MAY BE REVOKED BY THE CIT NORTHAMPTON UPON VIOLATIQN OF ANY OF ITS RULES AND REGULATIONS. "git Certificat@ of OC nc Signature: Fee Tyne: Receipt No: Date Paid: Check No: Amount: Building in/oo om:o0 4381 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo