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DEPARTMENT OF BUILDIhC INSPECTIONS
212 1\fain Street ' Municipal Building
Northampton, Mass. 01060
WORI{ER'S COMI ENS~AITION INSURANCE AFFIDAVIT
(li ccnserlper-mi tt cc)
with a principal place of bilsiness/residence at:
ZLI / G>.y
-- (st—t/city/stair-/zip)
do hereby certify, under the puns and penalties Of perjury, that
O I am an employer providing die following workers compensation coverage for my
emplovees working on this job:
(Lnsuran Cnzapam) —-- (Policy Nunnbcr) (E pirmtion Date)
( ) I am a sole proprietor, general contractor or hotneow-ner (circle one) and have hired
the contractors fisted below who have the follox'�ing workers compensation policies:
(Name of Contrnctor) (Insuranc: Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyiPohcy Number) (Expuzuon Date)
(Name of Contractor) Omsurano Company/Poticy Numb�,r) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shed ifmccssary to include information pertaining to all ooh-e..cto: )
I am a sole proprietor and have no one wor- ng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who employ persons to do M-m n-rIMN= COQ5tnra.ion or repair work on a d YCll of
not moon than thtno unit+in winch the homeowncr resider cc on the grounds apxrftcnant th=ere arc riot gcaerally wandered to be
elnploym under the worker's oomPCiszUca Act application try a homooavcr for a Gaase a permit may cvtd—the
legal etsuas of an anployoc under the Workzet CompCmation Act_
I understand that a copy of this rt tcmcat my be forwarded to tho Dcpertm w of indusz ial Aoodea&Offioo of lasruwoo for the
cova-age va iGatioa and that failure to tonne oovcrage under section 25A of MOL 152 can Lad to tha iMPOS60n of criminal pcnaitia
comisting of a Gee of up to S 1,300.00 andtor ofup to one year and civil penalties io the form of a Stop Work Order and a
fine of 5100.00 s day against mc.
For R—y,_•tn* fal—OOJy
� Pcruut Number
Map __ _lot n
Signature of Licen_s-u- Prrmiuce e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : f11� y' 'L1� 1� 0 Y-0-q�3
License Nu be
7
Addres Expira4on eate
Signature Telephone
9. Registered Home Im rdVement Con ractor: Not Applicable ❑„
�wP fovea— y ew A to /i-) o
Company Name Registration Number
Address J Expi/ationkate
�'
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...... ❑
11. - Home Owner ExieffiPtion
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 pen-nit 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)"If Roofing ❑
Or Doors ❑ IV
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] ,�J Siding [ ] Other [ ]
Brief Description of Propos.ed Work: "�`e 91-clew' ) 7r�4) Ch/rn ��>TO �oof � �Cby�/q�
lI we 7"wv 0/)trn`rvey SKp� r/. �`, .sT/ f'/fQrC / pveio5
Alteration of existing bedroom Yes- No Adding new bedroom _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If Newhouse and or addition to existing housing 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 Nc
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
�asO �the ubj ect property
hereby authorize to act c
my behalf, in all matters eIative to work authorized by this building permit application.
ignature of Owner Date Q
?942444) (iL 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.
/95�444 Ll�w
Print N e
6�90A�l _
Signature of Owner/Agent Date O C
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
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 X 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 A
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:
I�
rp F-
Department use only'
IZN'04 0'N1
.r.a s �
ity of Northampton S#atus�of P�errn � � �
4 2 �yilding Department rbGutl.Dri� ayT'err�t z r
212 Main Street Sewer/Septtd Ava�lakS l t
` Room 100 Water�IWel1Av �lbai�t%
DEPT OF BUI 'HIC,INSPECTIQQl-S
ali;6il�ort ampton, MA 01062 Two Sets:of Structural Flans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans`
Other Specify � �
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 Property Address::
9 S C? T/ Map Lot Unit
relktl'C 79 Zone Overlay District:
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: /
/-� 7�/%j/j " 45����yPt�c�
Name(Print) Current Mailing ddress:
Telephone
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 (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 =(I + 2 + 3+4 + 5) Check Numbers _
This Section For Official Use Only
Building Permit Numbe- Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
*= 71HM sT BP-2000-0826
Ws*, COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-133 CITY OF NORTHAWTON
Lot:-001
]Permit: Building -PERMIT
Category:ehimney_rebuild B V IL DING
Permit#_ BP-2000=4$26
Project# JS-2000-`1551
Est.Cost:$5600.00
25.00 PERMISSION IS HEREBY GRANTED TO
Const..Class: Contractor., License:
Ilse g1m: Andrew Church 104480
Loth" (aq_ft.): 38410,52 Owit�er:- ANDR Jj S BERNICE
Aunt: Arycho r Church< _
Al.- 95 97 HI H. ST
Ag cuntAddr Phone: Insurance:
174 S"nn St (413) 586-0918
FLORENCEMA01062 TSB UED 0 N:312910 fl 0:0 fl:4fl
TO PERFO"THE FOL,L0 ING WORK:REBUILD (2) CHIMNEYS TO ROOFLINE
W/SUPERELU CAST IN PLACE LINERS
POST,THIS QARD SO IT IS VIHPLE FROM'SHE 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:
Roughs Oil. Insulation:
Final: ma x: Final: d K 4-7-CP
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIObT OF
ANY OF ITS RULES AND REGULATIONS. ?5
Ce ificate of Occ S" Lure:
FeeTTvne�___� ReceiEt Date'Paid: Check No: Amou t::
Building 3/29/00 0:00:00 1629 $25.00
212 Main Street,Phone(413)5 87-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo