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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WOMCER'S COMPENSATION INSURANCE AFFIDAVIT
(Iicenseejpermlttee)
with a principal place of business/residence at:
v a a-� /�� ✓t �, Ceti% +r> (phone#) S.2 -3A!5"
(streei/city/ 2ip)
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:
AA 0035
(Insurance Company) (Polio 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 additional sheet ifnecenary to mehsde infacmation p=uiaing to all ooabm o )
( ) 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 while homeowncrs who employ pesaas to do mai tm-= constvetionor rcpai r work on a dwelling of
not more than throe units to which the homoowner resides or on the grounds appurtennat then t are not generally ooaridcred to be
empioyem under the vmdccft oampe¢saika Act(GL152,ss 1(5)),application by a homeowner for a license or permd may evidenoo the
legal status of as employer under the Worlceet Compensation Act.
I underataad that a copy of thin cut=ad may be forwarded to tbo Dcpdrwx d of rndustiel Acci4w&4ffioe of Iasurwoe for the
coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties
oomistittg of a Tine of up to 51,500.00 and/or of up to one year and Civil penalties is the form of a Stop Work Ordr sad
fmo of 5100.00 141Y spitut M
For dcpatrnexta1 use only
/ Permit Number
Lot#
, u
f;,_ t Of ermittee
l OMAN OAMI
M
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Hander
License Number
Address` Expiration Date
5
SignatureO Telephone
r
Not Applicable ❑
cz-u � G'v'a-*-,nom f C c� •-- � ? `�
Company Nam �1 Registration Number
tj O C c� 'L� �t A a '1` ct�v v� aY�- e ;;7-o "-1- —--2,
Address t� Expiration Date
Telephone
" °
SECTION310 'A"A AllS'COMPENSATION�INSt�„RANCE'AEF1DAVi7(M
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...... ❑
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(Wor ' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the ss setts General s Annotated,you may be liable for person(s)
you hire to perform work for you and this pe
The undersigned"homeowner"certifie and ss e espo ibility for opipliance wi uilding Code,City of
Northampton Ordinances,State and Vcal n' ws d S to of sachusetts Ge ral Laws Annotated.
Homeowner Signature
,»gin
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: S otef �, c�t• ,cam moo- �-� �' y-�v.-�-. -�-G �'^t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 11 Renovating unfinished basement Yes No
Plans Attached Roll 0• 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_
pp
3
A
N . y
4
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters rela ive to auth rized by th' uilding permit application.
Signature of Own Date
as Owner/Authorized Agent
hereby declare tha the statem s and information on the foregoing application are true and accurate,to the es of my
knowledge and belief.
Signed under the pains and penalties of perjury.
'k `- r*-/ /A 6if �Ct
Print Name
Signature of Owner/Agent Date
W..
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:
w
1
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587.1240 Fax 413.587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'� ' .II at, 333
S�EGTION 1„ S1TEfNs ' RI1I «,N :.... .
1.1 Property Address: x, .
a�
SECTIOIN PRCIPERTY OWNERSFTP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr�C4,41 Current Mailing Address:
`i Est(- 7ff�d�s
�Z �__ Telephone
Signatur
2.2 Authorized Agent:
CG
Name(Print) Current Mailing Address:
Signature Telephone
01W L`Q tTS
Item Estimated Cost(Dollars)to be 0ffc[at
completed by ermit applicant
1. Building �1 (a) Builtng Per� �E �
2. Electrical (t))Esttrted'� t�
3. Plumbing Bul`cttng Permit f;ee
33 v;
4. Mechanical(HVAC)
u y�
5. Fire Protection '
6. Total =(1 + 2 + 3 +4+ 5)
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BP-2001-0892
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2001-0892
Project# JS-2001-1620
Est.Cost:$5700.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette
Lot Size(sq. ft.): 11020.68 Owner: ADAMS RONALD S&DONNA C
Zoning:URA Applicant: ADAMS RONALD S & DONNA C
AT: 21 MOUNTAIN ST
Applicant Address: Phone: Insurance:
21 MOUNTAIN ST
FLORENCEMA01062 ISSUED ON:5/9/01 0:00:00
TO PERFORM THE FOLLOWING WORK:srtip and reshingle
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 Deaartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final
Smoke:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHXAPTON UPON VIOLAT N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/9/010:00:00 2722 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo