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17A-197 (2) 6 { � C ! -J Ilk E 41 s r � F� i 4 �i �° oy - $ � �lasazsckasctis m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street a Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (lipermittee) with a principal place of business/residence at: (/ ` L _ T (phone#) 09Y-61-N-5 (street/city/state/ap) do hereby certify, under the pains and penalties of pedury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Polio Number) (Expiration Date) KI am a sole proprietor, general contractor o Ei��(circle one) and have hired the contractors listed below who have the following workers 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 shod if necessary to include information pertaining to all ooatmdora) ( ) I am a sole proprietor and have no one working for me. VN I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ pusoae to do mainteaaDv_oonstructioa or rryair work an a dwelling of not more than three units is which the homeowner resides or on the grourx6 appurteaaai thereto are not generally oo=dat:d to be empioyrsa under the wmkces oompmsation Ad(GL152,ss 1(5))�applicadon by a homeowner fora license or permit may evidaooe the legal status of an employer under the Wodrees Compeoadiou Act I undentaad that a copy of this statement may be forwarded to the Depnru..A of I.uitrid Aaddart>r Offroe of Insruaace for the coverage vetiftwim and that failure to secttre oovetaga under section 25A of MGL 152 can lead to tha impost -of criminal penalties ooausti ng of a fate of up to$1,500.00 andlor impaisonment of up to one year and civil penalties in the form of a Stop Work Order and a 1 faro of$100.00 a day agaira me. For dgna4necbl tuo only Permit Number 5 Map# hot# Signature of LicenseelPermittee Mte SEGTIbIV.13-C NSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 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...... ❑ 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 Zonin Laws and State of Massachusetts General Laws Annotated. Homeowner Signature L UPTION 5_.D9AC 81PT1PN,OE PRQROS 0 _ck all applicabl New House ❑ Addition ❑ Replacement Windows Alteration(so Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolitior> New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: '�'(i►ti© `�" Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 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 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 SECTION 7a -OWNlI R AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENTiOR�CONTRACTOR APPLIES ObR BUILDING PERMIT yt!` as Owner of the subject property hereby authorize to act on my behalf, in all mat s relative to wor c ed by this building permit application. Signature of Owner Date I, 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 painsfany penalties of perjury. Pr Name 1 Signature o wne /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 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 i /Variance/Finding ever been issued for/on the site? NO _ DON'T KNOW YES IF YES, date issued: IQjs� IF YES: Was the permit recorded at the Registry of Deeds? NO k_ 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: ArlslRfiqhloWw olm su I t* w E ity of Northampton uilding Department 212 Main Street APR 3 0 � Room 100 Nor hampton, MA 01060 OED OF WWK 1N413- 87-1240 Fax 413-587.1272 NM W�N�TON MA 01060 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,ECTIQN I-SITE INFQI MAT1.ON /rp 1.1 Property Address: Fe 1 ! D ,' t''�k`1-" IR i SECTION 2-;PROPERTY OWNERSHIP/AUTHORIZED AG1 NT 2.1 Owner of Rec rd: ac& 'K"—mat:YIJU-K-10 Nam (Print) Curr nt Mailing Address: LYN_ 9 3 --- Telephone Lka Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature 1 Telephone fiK6TId1V 3 ti" IMA�`ED CON THE trTtON C" Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Lost of Construction from 6 3. Plumbing 40c)-O, 0 Building;Permit Fee_ 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) Check Number This Section For Official Use Only' Building-permit Number: 4 l"- f _ cal)44 Date Issued: Signature: "' ` Date Builging.Cpm,n ssioner/inspector of BullOings rr BP-2001-0874 s#: COMMONWEALTH OF MASSACHUSETTS IV 111100 X woo CITY OF NORTHAMPTON Lot: -001 Permit: Building Categrv: BUILDING PERMIT Permit# BP-2001-0874 Project# JS-2001-1606 Est.Cost: $3150.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq.ft.): 9104.04 Owner: NORMANDEAU BRETT& Zoning: URB Applicant: NORMANDEAU BRETT & AT. 149 NORTH MAPLE ST Applicant Address: Phone: Insurance: 149 NORTH MAPLE ST FLORENCEMA01062 ISSUED ON. TO PERFORM THE FOLLOWING WORK.RENOVATE BATHROOM AND PANTRY 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 NORTHAMPTbN UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: Fee Type: Receipt No: Date Paid: Check No: 'Amount: Building ( 151 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo