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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I-,
(Iicensee/Permittee)
with a principal place of business/residence at:
(phone#)
(street/city/stateJrip)
do hereby certify, under the pains and penalties of perjury, that-.
(v6 am an employer providing the following worker's compensation coverage for my
employees working on this job:
� �ri��.�'� 1 I�� 1 li�i� ��� 4.-\1 (•.. l" �f.,.<-�n r. j"..(�1�l,� -'/a�A'.�a l�.G"'�r
(Insurance Company) (Policy Number) (Fxpiration Date) �;{; ?sYr
( ) 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) 0
r
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Inwrance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(artadr additioml shed ifnecenary to include infotmarion pertaining to all coats )
( ) 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 vehi]o homcowneca who employ pcssoru to do a&inj�coasuvction or repair work on a dvmiling of
not maro than throe tarts is which the homeowner reside-or on the grounds appurtenant tb=w arc not generally considered to be
employe-under the worker's compeamtica Act(GL152,ss1(5)�application by a homeowner for a license or permit may evidence the
Icgal ctatrra of an amployor under the Worlceet Compomation Ad.
I unduatand data copy of this ctat—ent may be forwarded to the Dcparrmmt of Industrial Accidca&Offioa of Insurance for the
coverage verification and that failure to uxurt ooverag+o under soetiou 25A of MGL 152 can lead to tba im po$ on of au-31 penalties
comisting of a fine of up to S 1,5oo.00 andlor imluisoamctti of up to one year and civil penalties in the form of a Stop Work Order and a
f=of 5100.00 a day agai nt me.
For d-p�use oily
� t%' permit Number
#
Signature of Licensee/Permittee 'Mte
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
o -7
Address Expiration Date
Signature Telephone
Not Applicable ❑
si
Company Name y Registration Number
Address Expiration Date
jJ Telephone. 6
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(
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 5 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"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
P P' II appiicabl e
New House ❑ Addition ❑ Replacern Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[1,] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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 AUTHORIXATION -TO DE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l �, °i,'_? /'� /�.!'r� ✓ := as Owner of the subject property
hereby authorize Z—: '1='-t�'J r.-1 -�/' �'`� to act on
my behalf, in all matters relative to work authorized by this building permit application.
/
Signa�f Owner Date
I, r t%> iii j r 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
7 -,
f;
Signature of-Ow"af/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:
- -- Northampton
B I g Department
Main Street
R om 100
r,lNsE'EdSJ&%ham ton, MA 01060
h 40 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
s
1.1 Prooertv Address:
t � �� �i 1!'�l V 1.1 f,f I j✓ opt� �,'. ##r- �%s l��/ � ✓�
F..ks_"1 �irl� {• L..` ��t'I��— �1�I�x t�' r,, �A�ne �'a \ _ 4",.'v v v / `. .'s'�'
-SECTION 2"..PROPERTY OWNERSHIPIAUTHOIRI ED AGENT
2.1 Owner of Record:
Name Print) Currents j aiiin�Address:
t- ,'( Telephone 1 01
Signs ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature ! Telephone
StOPON 3 -OTIMATED CONSTRUCTION COS`E5
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �.� u (a) Building Permit Fee
2. Electrical (b) Estimated Total Cast of
Construction from 6;
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection �r
6. Total =(1 +2 +3 +4+ 5) Check Number
p
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of Buildings date
BP-2002-0188
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate og ry:replacementwindows/sidinc BUILDING PERMIT
Permit# BP-2002-0188
Project# JS-2002-0292
Est. Cost: $12365.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sg.ft.): 8799.12 Owner: OLANDER WILLIAM P&DEBORAH L
Zoning.URB Applicant: B & R Sidinq
AT. 15 STILSON AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAM PTO NMA01060 ISSUED ON:8116101 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & 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 UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Silznature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 8/16/010:00:00 17806 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo