17C-126 1
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
•` (licensttJpermittee}
with a principal place of business/residence at:
Ott -;
�. ` "a-treeticity/stafe/�p) r��y
(phone#)
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:
(las-u ce 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:
(Name 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 Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml sbcct ifneccsiary to include information peria.ining ton ootradors)
( am a sole proprietor and have no one workzing for me.
( ) I am a home owner performing all the work myself.
NOTE:plcsse be aware that while hoa>)owocta who employ perzom to do t imm3 ncc masts c on or repair work on a dwelling of
not more than throe units in which the homeowner midc s or oa the grounds apputtenani thcrc(o arc oo(gcocraky coasidacd to be
employtn under the worker's compca sUm Ad(GLI52,ss 1(5)),application by a homcow=far a Boa=or permit may-id—the
legal ctatua of an employer under the Wockor'e Compamation Ac(-
I undentaad that a copy of this cutemmt may bo forwarded to rbo DVwtra of lndlLiUid Aodde-&Offioo of fusur*nca for the
covaxge venficauon and that failure to seethe coverage under section 25A of MOIL 152 can lead to tbo impositioa of aiminal penalties
coasiuing of a fine of up to 51,500.00 aadlor of up to one year and civil pc>z Wcs in the form of a Stop Wade Order and a
find oCS100.00 a day against me.
Foe departwe use coly
Permit Number ��/r
.�!'f/t'i...L.- ?``,<?,� .`/j G.,�../„t/•- mil( Lot tt
Map
�. S;g=bire of Licenswipermittee Date 1
-srs
F
8 1 Licensed Construction Supervisor: y Not Applicable ❑
Name of License Holder
1 Lice— n�e(dumb r
Addle o Expiration Date
Sin ure Telephone'
v. e Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
S CTIOtJ30 WORKERS' COMPENSATION=INSURANCE AFFII)A1/IT(M GL c:152, §:25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affida
will result in the denial of the issuance of 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)familie
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(
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 �
i
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�. C PR= .
MORRIS
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom - Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet D
f MMMMUR1700b e' y'Sflt1 1
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 f
j. Depth of basement or cellar 11oor 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
as Owner of the subject property
hereby authorize to act
my behaV, in all maters re ve to work authori e by this building permit application.
Signature of Owner' Date
as Owner/Authorized Agent
hereby eclare 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° ame
Si ture of Owner Agent Date
:x
: »7: _
l
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:
xr
y of Northampton
SEP 1 0 2001 ilding Department
12 Main Street
Room 100
DEPT OF BUILDING INSPECTIONS Nort ampton, MA 01060
NORTFlt4g1PTON,M 01060 7-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFfJFMATION;
'ThIsec 4
1.1 Property Address: k R*
y Zo e .
SECTION 2-PROPERTY OWN:ERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
¢ z '
Name(Print) Current Mailing Address:
'7 yr,.
Signat r Telephone `
�5EC1"I�N 3 `ESTIMA'TED�Gt��SThIt�T10�1�CO5TS�
Item Estimated Cost(Dollars)to be � y
corn leted b ermit a licant
1. Building '(a) Building PerrriitFee
2. Electrical (b) Estimated Total Cost of
Construction fi !? 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'On) Q
Binding Perrntt Number Date lssued
77 77 ge TR
SgnaLlE' w>r r
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a NEORTx ivtkPLE ST BP-2002-0274
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CIS#: COMMONWEALTH OF MASSACHUSETTS
:Biock: 17C- 126 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofm BUILDING PERMIT
Permit# BP-2002-0274
Project# JS-2002-0410
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq.ft.): 12632.40 Owner: STENSON ERIK L&JANE R
Zoning:URB Applicant:James Roberts
AT: 67 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:9110101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 Sh!nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/10/010:00:00 1387 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo