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17A-193 R i M � n � .F, .. .. ,i .. i 4Tt pT0 9 g �x C7 'Nart4aiilptoIl 9 B �assachnsctta DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 " WORT-ER'S COMPENSATION INSURANCE AFFIDAVIT with a principal place of business/residence at: S-o Y101CC fC S`! (st=Ucity/stale/rip) do hereby certify, under the pains and penalties of per}ury, that: O I am an employer providing the following worker's compensation coverage for my employees worming 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance CompLriy/Policy Nambe ) (E.\piradon Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (amach additicxW rhod ifncccz to inchsdc infocnutioa pertaining ie all ooctrac ion) 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 homcoAjxrs who cmplay pazoms to do¢ling 'caLn Gino or repair worse on a d%vetliog of not mace than thmo units in"inch the homeowner raids or on the grounds appurtenant jS do a,oo(gcnaraily oomidcrcd to be employes under the worker's ration Act(GLI52,ss1(5)),appliraflon by a homeowner for a Bernie cc permit may evidence the legal status of an employoc under the Wockceit Compomation Act I wxka tared that a copy of this uatcmeat may bo forAwdad to tho Dcpnr�of Industrial Amdmtf Offioo of Imiuincn for the coverage verification and that failure to&earn coverage under sociioa 25A of MGL 152 can lead to the imposition of aims W pcnaltics ooausUn of a fine of up to S 1,500.00 andloc imprisonmart of up to one year and civil peaalti a in the form of a Stop Work Ordcr and a firm of s 100.00 1 day against me- FCC departnt ow uio only Permit Number /9 4 — Map t Lot# Si of LicenseelPermittee e SECTION 8-.CONSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone relN e,: u" nen . Not Applicable ❑ Company Name Registration Number s 4M o>a s` ��io% �- Address Expiration Date Telephone ✓e�y�87�Z 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 Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature . 3 SECTION 5 DES�C RIPTfONOF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding„[ Other [ ] Brief Description of Proposed Work: A—YL Si / c VS 4E?— Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a If I�e�ni h "s aFi i ti"r ddit161fto ezi'tihit ousin� ..coml�lWAR6j: x 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: i City of Northampton Building Department 212 Main Street e Room 100 Northampton, MA 01060 Se ax 413-587-1272 413 587 1272 F' ISt P AP I ION T C ST CT, , REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING OEM 91 FH!�PNG SECTION_ by41 0!(60 1.1 Property Address: This section�to�be�completed b offace .> O `1000W&—u_ cs Map Lot � .. , n "" s� ter; kv � �— Zone Overlay bistr�ct ¢ Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: CTMr-por It- � N�sse�- --z� P©w4--u. Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: .�-4 °t1 7,/ 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 =(I + 2 + 3 + 4 + 5)-- 3 + 4 + 5) �.SD. Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2002-1150 0" GIS#: COMMONWEALTH OF MASSACHUSETTS sk:17k- 193 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2002.1150 Project# JS-2002-1846 Est. Cost: $6430.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: John Corbett 104000 Lot Size(ss . ft.): 8668.44 Owner: VANASSE GERARD R&NANCY B Zoning.URB Applicant: John Corbett AT: 30 POWELL ST Applicant Address: Phone: Insurance: 56 Dimock St (413) 586-8712 LEEDSMA01053 ISSUED ON.6124102 0:00:00 TO PERFORM THE FOLLOWING WORK:I N STALL V I NY L S I D I N G 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: Driveway Final: 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 6/24/02 0:00:00 1360 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo