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m DEPARTMENT OF BUILDING INSPEC'T'IONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFEDAVIT
(i1ermittec)
with a principal place of business/residence at:
12— (4L .LI-C ST• �/��, C tf/4h,��U,� ��t� Qf� (phone#)
(st i=Uci ty/siai&2i p)
do hereby certify, under the pains and penalties of penury, that
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Lasux ncc 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 workees compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(Name of Contractor) (Insurance Company/PoGcy Number) (Expimdon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inu=re Company/Policy Number) (Expiration Date)
(-"-rh additional shcct ifn6o=siry to iocbade informitioc pauinino to all ooatr.0 r7)
(iJ�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 homeowners who cmplay pcao=to do mj is,t • n o sstvctioa or repair-uric ou a dwelling of
not more than chino units in Which the homeowner rexidea or on the grounch appurtenant tha+cto arc not generally oocsidacd to be
—Tloycrs under the wodlcci's cc mpensatioa Act(GL152,sa 1(5)�applica0oa by a homooWna far a li—a permit may evidcaoe the
legal datus of an employee under the Wocicees convoxm6on Ac
I un&rstind that a copy of this etalcmmi may be forwarded to the Dc mAmcnt of L>dusb-ial Arad=&Ofboo of Lm nee for the
oovanc verification and that failure to s==covcrap tntdcx suction 25A of MGL 152 can lead to the imposition of criminal penalties
oomistiag of a fine of up to S1,500.00 and/or imprisowncnt of up to one year and civil pemltics in the form of a Stop Work order and a
firm o(5100.00 a day against me-
Foe dqurimtd-i u1O only
permit Number
Map's Lot#
Signature of Licensedpermit tee e
S��'i0��8� (1�ONST�RUCTIOIV,SERI/ICES`� ���'
N�
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: U10 Ise)/-7 1 n 007 Q°-�f
License Number
5 it
Address r` Expiration D e
Signature Telephone
> i,e mpr vement4ntnc�tor Not Applicable ❑
Company Name Registration Number
Address Expirati n Date
Telephone
SECTION 10 ,WQRKERS' 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 affidE.
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ® No...... ❑
REM, lmi4Tcl�O"�ll
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
� 3k+$�a�u
SECTION. DESi' Ta10' OPROPOSED�IORF ch'+�cka�lla I�cable s
New House ❑ Add ement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[of Other [ ]
Brief Description of Proposed WorkAuiko 3
Alteration of existing bedroom Yes No Adding new bedroom Yes '� No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet El
fia, If Ne o s id or FRO itiME6200'01rig`thou§J'h 0ffi ale e th f611-o ift
a- Use of building : One Family y Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
I r
d. Proposed Square footage of new construction. I'-` Dimensions J q tp
e. Number of stories?
f. Method of heating? A � 9-Al Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction 110J6 FAAhR
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
j. Depth of basement or cellar floor below finished grade�ok A Tula >
k. Will building conform to the Building and Zoning regulations? tX Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION7a OWNER�At1XHO11ZATJON TO BECOMPLETED WHEN
O. NERS AOEITCt CONT]tAGTOR,ARPL IESxMR BUNLDfNG PERMIT
""TM
J
•t1 j L ✓� r �w-1 as Owner of the subject proper
hereby authorize
i'� f° .�Y °7�> t to act
my behalf,,in all matters relative,to�ork authorizedtby this building permit application.
Signature of Ow r Date C�
/V, rU!S--T A4 aster/Authorized Agent
hereby declare that the statements and informa ion 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 (�
3 a �
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
ZOT .�vK lo��j S�f
Lot Size L°' aar 9 tlac Sc Ft
Frontage
Setbacks Front 5-31 a 6
Side L: R: L: 6-D R:-93 /J4*--
Rear � 1 7 � !
19-0
Building Height 2 c�
Bldg. Square Footage 1 5-5-6 a4ft r2. ? %
Open Space Footage c % (Q r?
(Lot area minus bldg&paved
parking) / 0
#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:
of Northampton
EC E Q ing Department
2 Main Street
Room 100
SEP - 4 2001 N mpton, MA 01060
phone 41 -58 -1240 Fax 413-587-1272 P l e
DEPT or BUILOISG INSPECTIONS
N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-5ITE4NFORMATION
1.1 Property Address:
IN
AL
d
S; Map °�L # Untt :
�}
3 - 1
Zonea ` Overlay D�stnct
EImSt.°District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ITVi tP✓ y CLAIQe. 01(?rj A/v 3 S f.
. Print �� I— y-� tc
Name
(Print) Current Mailing Address:
° a Telephone
Signatur
2.2 Authorized Agent:
DA Q i /�1 >�U 2? I('ti j2 3� L��;n,-Z t S 0
Na (Print) Current Mailing Address:
6- 6- � �
Signaf6re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars) to be Official Use-Only
completed by ermit applicant
1. Building 3 �) d O V (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
& L Construction,from 6`
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) *'15-7 so r G (: Check Number
This Section For Official Use Only
B floi, rmit Number: Date Issued:
Signature
Building,Cornmissto er/insp of ector Suildirlgs Date,.
File#BP-2002-0254
APPLICANT/CONTACT PERSON David Fortier
ADDRESS/PHONE 32 Laurel St (413)586-8965
PROPERTY LOCATION 31 POWELL ST
MAP 17A PARCEL 204 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyueof Construction: CONSTRUCT 16 X 14 3 SEASON PORCH&INSTALL VINYL SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 008026
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94(MATION PRESENTED:
Approved Denied
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan OR Special Permit and Site Plan
Major Project: Site Plan OR Special Permit and 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 C ission
CJQ
Signa 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.
i
t°POVlLL ST BP-2002-0254
COMMONWEALTH OF MASSACHUSETTS
"1VI�RBloclt: 17A-204 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: ADDITION BUILDING PERMIT
Permit# BP-2002-0254
Project# JS-2002-0390
Est.Cost: $35750.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: David Fortier 008026
Lot Size(sq. ft.): 10585.08 Owner: DIEMAND WILFRED A&CLAIRE L
Zoning_URB Applicant. David Fortier
AT. 31 POWELL ST
Applicant Address: Phone: Insurance:
32 Laurel St (413) 586-8965
NORTHAM PTO NMA01060 ISSUED ON:9111101 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X 14 3 SEASON PORCH &
INSTALL VINYL SIDING
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 9/11/010:00:00 3762 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo