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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKE,R'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place, of business/residence av
do hereby certify, under the pans iand penalties of perjury, th-it:
O I am an employer providing the following-workers compensation coverage for my
employees work:ing on thus job:
(Iusuranov Company) (Polio Number) (Expiration Daze)
O I am a sole proprietor, general Conti actor or homeowner (circle one) and have hired
the contractors hsted below who have the following worker's compensation policies:
(Name of Con��-actor) (Insurance Company/Pokce Number) (Expiration Date)
(Name of Contractor) Qnswanc (Ea-piration Date)
(Name of Contractor) (Insurance Company/Policy Numbs) (Expirnon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expimbon Date)
(auarh additional shoct ifne�to iaclu(ic information pctaining to ell 000hncdora)
I am a sole proprietor and have no one working for me.
( I am a home owner performing all the work myself.
NOTE:plczu be aw;Lm tbxt whilo homcownal who employ persom to do m+%^r� m w c coasruaioa or repair work on a of
not mace than tbroa unit+in which the homeown r r c=da or on the Bounds appurtcnnrd thcr e4 arc oo(graa.11y 000sidacd to k
employes under the wxkcr's ocmpcaation Act(GL152=1(5)�application by a 6omcow=for a license or permit may cvidcnoc the
legal ru&u of an employer under the Woclrcla Compomatiou Ad
I underct.aad dml a oopy of tbu mrcmcaz may be forwarded to the Departmcvi of Ad-n&Offioe of Imurwco for tho
oova-age vaiftatioo and that Uun to aeauc covcrnga under scction 25A of MOL 152 can lord to the imposition of criminal penalties
oonsisutg of a fine of tip to S1,500-00 and/or imptuoomr�of tip to 00C year and civil pcmltia io the form of a Stop Work Order and a
firm of S 100.00 a day t&uwl mc-
Fcc d.y�*n tai uac only
Pmwt Number
ma Lot"
Signature of LiccnseelPcrn ittce UaLe
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable,�❑
Name of License Holder : �K/r��m Gy ( '/l L/✓�� 0 yo`-,5 .
License Number
Address ! Ex rati n Date
Signature Telephone
9:ReeliW &Hdmlli°IFn t. ```Fn. n r`c ' t Not Applicable ❑
r--eet)
Company Name Regis— try Number
/ 7
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...... ❑
on.
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
SECTION 5- DESCRIPTION OF PROPOSED WORK(check:all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other jl�]
Brief Description of Proposed Work: jr7r eA We/ /� ��/---y-lof4 f)/ ,/ytcv,�'��c/� � 14SA� vg
Alteration of existing bedroom Yes X,_No ✓Adding new bedroom Yes X No
Attached Narrative❑ Renovating unfinished basement Yes A,, No
Plans Attached Roll ❑ - Sheet❑
6a, 1f-New house a` d oradd-Iflon—to existing hotiSingr, complete the following:
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 AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, &r W/3 c: ,/Q/l✓d/��S as Owner of the subject property
hereby authorize / ✓ IC4-e tL) exa J G X to act on
my behalf, in matters relative to work au rized by this building permit application.
Signature of Owner Date
CA14 C�ti 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.
W CA-ru.) C A u cr6_L/
0
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&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 _
Nov
IF YES, describe size, type and location:
art I�t
Crt of Northampton l Me
L) Ia l 'il �u ding Department tlCrt e4 ` iii
242 Main Street
" a MAY 3 20M Room 100 We y
Northampton, MA 01062
rT 0F
phon `-4TT3'-b87-1240 Fax 413.587-1272 t �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
26
Map Lot Unit
1- 0 - :�
Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERS HIP/AUT'HORIZED AGENT'
2.1 Owner of Record:
Name(Print) Current Mailing A dres
�-VeAln
Telephone
Signature
2.2 Authorized Agent:
Name(Pri ) Current MailinErAddresy.
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) �-
5. Fire Protection
6. Total =(1 + 2 + 3-+4+ 5) Check Number
This Section For Official Use Only
Building Permit Number: �� � Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
93 HIGH ST(REAR) BP-2000-0981
GIs#: COMMONWEALTH OF MASSACHUSETTS
. IaQBlock: 17C- 133 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: chimney rebuild BUILDING PERMIT
Permit# BP-2000-0981
Project# JS-2000-1787
Est. Cost: $1150.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Andrew Church 104480
Lot Size(sq. ft.): 33410.52 Owner: ANDREWS BERNICE
Zoning.URB Applicant: Andrew Church
AT: 93 HIGH ST (REAR)
Applicant Address: Phone: Insurance:
174 Spring St (413) 586-0918
FLORENCEMA01062 ISSUED ON.514100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY TO ROOF BRICK &
FLASHING
dM 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 5/4/00 0:00:00 1659 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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SP-2004-0981
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It. vF MASSACHUSETTS
M,-.Block- l'C "113 CITY OF NORTHAMPTON
Lot:-001
Permit Building
Category:chime"rebuil d BUILDING PERMIT
Rerun# BP-20QQ-0981
nroNt# JS-2060-1787
Est.Cost:$1150.00
fte:$21A PERMISSION IS HEREBY GRANTED TO 1
, t. ass: Conhactor: License:
Case Group: Andrew Church, t� 4480
W%ze(sq&133410,52 Owner: ANDREWS BERI*tICE
A�ffitang Andrew Church
AT: 93 H raH $T (REAR)
, .
A l�rcantAddressc Phone: Insurance;
174 Stukng St x'4133 5$5-0918
FLORENCEMA01 062 ISSUED QN:51/00 0:00: At
r
TO'PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY TO ROOF BRICK &
FLASHING
POST IH CARD,^,_ S{ )I'T'IS' IS E FROM THE STREET
Inspector Of Plumbing Inspector(if Wiring D,P,W. Inspector of Buildings
:Underground Service: Meter:
Footings:
Roughs Rough: House# Foundation:
inat• Final:
Rough Frame:
Gas Eire Department Fireplace/Chimney:
Rough: Oil, Insulation:
Final: make Final:Q K
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITiUI.ES A REGULATIONS.
G f'cat f cu' an s` n r`:
Fee Type: Receipt No hate Paid: Check No: Amount:
Building 5/4/00 0:00:40 1b59 $25.00
"Now- -
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