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m DEPARTMENT OF BUILDMG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE ATrITDAVIT
(Iicensec/permittec)
with a prmi cipal place of business/residence at:
Ah e °,r� 4 3 2
(str�t/city/stalr/rip)
do hereby certify, under the pains and penalties of pcqury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance 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 CompanylPolicy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E,\Tim ion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addi`ioezul sheet fnecc=. to include inform1hoa pertaining to all ocatradors)
( ) I am a sole proprietor and have no one working for me.
Q I am a home owner performing all the work myself.
NOTE:plcaae be aware that while homcowl)cn who employ pc-rom to do maintma .ca mud ion or rcyoair work on a dwelling of
not more than throo units in which the hom oN;m r r=dca or oa the g vjr 36 appurtenant thado art no(gcacralty oomidacd to be
employes under the worker's ccatp�on Act(GL152,ss 1(5)),application by a homcownct for a licc=a permit may cvidcnoe the
Ie911 stntuy of an amployer under dw Workeet Comp*xviion Azt
I un&rrtand thzt a copy of this statrmmt may ba forwarded to tbo Dva jn of lo&r al Accidea&offioe of Iua-for the
coverage verification and that failure to seam coverage under sccUon 25A of MGL 152 can lead to the imposition of criminal penalties
oomisting of a fmc of up to S1,500.00 an&or ffijpi sonmatt of tip to one year and civil pc, l ,s in the form of a Stop Work Ondcz and a
film of 5100.00 a day t&inst tnc-
For dq-rtmtal use only
Zz Permit Number
lviap;t Lot#
Signature of icmSeepermittee e
SECTION.$—.CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
RR to �d ' ' m rgvement Contiacto...... t" Not Applicable ❑
Company Name Registration Number
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...... ❑
e , ,-aft if
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)
7 77777777F7,,, �--� ,, ,_
New House ❑ Addition r Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
4-Brief Description of Proposed Work:Cons+'ucF a t 3 S e A4Y�nle 001P M
Alteration of existing bedroom Yes L1 No Adding new bedroom Yes ✓ No
Attached Narrative❑ Renovating unfinished basement Yes j_No
Plans Attached Roll ❑ - Sheet❑
6aIfNewfl0"uses°nd 'ota"c!d"itio"n=.to�eiclstin �:lious"in" .:com` lefe�the:follo�v°iin""-:
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 (3 X S
e. Number of stories? 1,
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 f No. Is construction within 100 yr. floodplain Yes No
i
j. Depth of basement or cellar floor below finished grade Z
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
(rL/ (� y'1VI U►0\ as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
77/nA
Signature of Owner Date
12,4 6A^IX as Owner/Authorized Agent
hereby declare that the statements and infoOnation 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
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 9000 S l- ' �r
Frontage 7V
Setbacks Front (� O
Side L: Z R: L: R:
Rear eo tot �O
Building Height .3
Bldg. Square Footage 3-;k %
Open Space Footage 75'x /2 A % r y�
(Lot area minus bldg&paved 7S X 1?,p
parking)
#of Parking Spaces
Fill:
volum7&L. ation
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES ✓
S�pf�'L
IF YES, date issued: M9 - 99
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:
City of Northampton t
�.' t(n f -jj1 ing Department
i 'r`���'=-- " ?12 Main Street S
Room 100 a
A1°I9 ? 3 7002 Northampton, MA 01060
phone 41+3-58f7-1240 Fax 413-587 1272
O�erS ecT �
APPLICATION TO-CO-N&TACT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be m
copteted� y office
1.1 Property Address: � a
N1a Lottt
�p Zone, `Overlay Distrf t
Elm St. District - CB District"
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
M aCA-re" �� it ex ty c e- r o
Name(Print) Current Mailing Address:
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 =(1 + 2 + 3 + 4 + 5) Check Number 15,114 Sd
This Section For Official Use Only
Building Permit Number: f��- �c� a� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings,, Date
i
i
File#BP-2002-0920
APPLICANT/CONTACT PERSON RYAN MAUREEN
ADDRESS/PHONE 18 CLAIRE AVE (413)585-1032()
PROPERTY LOCATION 18 CLAIRE AVE
MAP 17A PARCEL 116 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 01f If you
Typeof Construction: CONSTRUCT 13 X 5 ENTRANCE ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ITSFP"ATION PRESENTED:
V'Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co sion
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
18 CLAIRE AVE BP-2002-0920
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 116 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinja
Category: BUILDING PERMIT
Permit# BP-2002-0920
Project# JS-2002-1496
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 9016.92 Owner: RYAN MAUREEN
Zoning: URA Applicant: RYAN MAUREEN
AT. 18_C-HIRE AVE
Applicant Address: Phone: Insurance:
18 CLAIRE AVE (413) 585-1032 (�
FLORENCEMA01062 ISSUED ON:4126102 0.00.00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 13 X 5 ENTRANCE ROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation: #01—ES 41r. ° 3_02
Driveway Final:
Final: Final:
Rough Frame: 0 4411
Gas: Fire Deaartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: Qk' 61 .70 -69-4�"
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N O
ANY OF ITS RULES AND REGULATIONS.
5 S•
Certificate of Occu arf6V i nature:
Fee Type: Receipt No: - Date Paid:— Check No: Amount:
Building 4/26/02 0:00:00 594 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo