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and of Building Regulations and Standards
One Ashburton Place - Room 1301
Boston , Massachusetts 02108
Home Improvement Contractor Registration
Registration. 120052 Expiration= 10/10/01
Type: DBA
LAMORE LUMBER & SON
WILLIAM LAMORE
RTE 5 & 10
DEERFIELD MA 01342
c'« :151 FM P*4f_""h:111i:,v Z CH0ii. 41 xe: 4{t, F. 01
TrSLWIVZSFr�yCaaua)#�''�"'
A-ON0"ftt1ri�"�" WORKERS COMPENSATION
AND
EMPLOYERS LIABILITY POLICY
TYPE AR IN 100R, MATION PA(39 wC 00 00 01 ( A)
POLICY NUMBER: (fxU8-°?38X391 -4-Oi )
R ENE WA,,� OF (US-5s6XI10-1-00)
INSURER. THE TRAVELERS INDEMNITY COMPANY
1, INSURED. NCCI CO CODE. t 13,47
LAMORE. WILLAM G DBA LAMORE PRODUCER.
LUMBER CO PARTRIDGE-ZSCHAU INS
ATE 8 8 .a PULLERS FALLS ROAD
DEERFIELD MA 01342 P ,0. BOX 312
TURNERS FALLS MA 01376
Insured 16 AN INDIVIDUAL
Other work pieces and kientlfleation Inurnbers are sn.owrs In Ire scheuulq, ) att3c+leC.
9. The pollcy perloo la from 04-11-01 tc 04-08-02 !2:01 A V at the Insursd's mailing addreas,
3. A. 'WORKERS COMP&N8ATION INSURANCE; Fart One 0 tlse p09ECy RPPI46 to the Workers Compen-
tiaticn Law of the state($)listed here:
MA
a
B- EMPLOYERS LIABILITY INSURANCE: Part Two Of the
Item 3.A, The iimMs Of our liability under Part Two Are: Policy applies to work In each state listed!r
9oa1y injury by Accident: s 1 00000 Each,Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease. x 100000 Each Employee
C. OTHER STAYER INSURANCE: Part Three of the pci:cy appiles to the states, any, listed mere;
SEE ENDORSEWNT WC 203 03 06
c-
D. This Polley IrlCiudes these endorsements and schedules;
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
MAY 12001
4. The premium for this �I
s policy will be determined by our t�antrels of 19uies,Ctaashficatbns, fetes and Rat!h0
. Mans. Alt recIored Ir l'UmattiOn is subject to verification and Changs by audh to be made ANNUALLY,
DATE OF ISSUE: 04-18-G1 TR ST ASSIGNS MA
OFFICES ORLANDO INDUS AFF 461
PRODUCER: PARTPIOGE-ZSCHAU INS 28DJJ
come
i
,
4�t1AMP2O
� -
$ B �asaxc}lnsrfta'
DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE ATT ANTI'
(licenserJpermittec)
oath a principal place of business/residence at.
(phone#)
(streei/city/StatrJzip)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the follolvving worker's compensation coverage for my
employees working on this job:
(I-ns=ce 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 Numbcr) (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 additiorW shed ifnecec to include informarioa prxtainiug to all oo'adors)
O 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 homeovvcrs who employ perrona to cb manEcaincc,=,stry oa or repair work on a dwelling of
not afore than thrre units in Which the homeowner mires or oa the grounds appurtcnnal thacto arc no(gully oo-=datd to be
employaa under the world's.00mpcmatioa Ad(GL152,ts 1(5)),application by a homcownr for a license cc permit tray evidence the
legal datua of an employer under the Worker's compomaiioa Act
I understand that a copy of this may be forwarded to tho Depwtmcu2 of Industrial Ac6d=&Offloe of lawrwoa for the
covcsxge verification and that aecttte coverage trndet soctioa 25A of MGL 152 can tead to the impositioa of criminal penalties
-a istiag of a fine of up to S 1 and/or imprisoamrnt of up to one year and civil pamttio in 6a form of a Stop Work Ord-sad a
firm ofS1W.00 It day agairsst
r
r`
For d p=t0dal use o°ly
Permit Number
Map'# Lot#
Signawm of UcevseelPermittce e —_
;SECTION 8 �CONSTRUC7IQN SERVICES °3 1.
8.1 Licensed Construction Supervisor: Not Applicable [Zr
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
S: Rem s� eretlYHbme,liinprovement Contractor $ �� g ' Not Applicable ul�
Company Name Registration Number
Address Expiration Date
Telephone
.SECTIONr10- 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 affid,
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑ ,— S f
om�e Ovine etri"t n
.,
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili,
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act-
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
SECTIONS DESCRIPTION OF PROPOSED%WORK{eheckllapplicable)
z..•fh 3 rm,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. X Demolition❑ New Signs [ ] Decks
[ ) Siding[ ] Other [ ]
Brief Description of Proposed Work:-7etio
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet❑
s .If Ne Mdfite"end W6Jdition1o7&1X s"thf dousing; corriplete the follbwin
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
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 OWNER AUTHORIZATION -TO BE COIOP,LETED WHEN
OWNERS GENT OR:CQNTRACTORAPPLIES fOR':13UIt.DING.PERMIT
I' as Owner of the subject proper
hereby authorize to ac:
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I' as Owner/Authorized Agent
hereby declare that the statement and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Z /'9 /
Print N
gnature of Owner/ gent Date G /
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT`CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Z ping
This column to be filledlin by
Building Department
Lot Size
Frontage
Setbacks Front S/''
Side ✓/ L. ✓�R: Y L: R:
Rear
Building Height
Bldg. Square F o a %
Open Space Footage / %
(Lot area minus bldg aved ✓/
ark in ) 7 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 L1 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 e.//
IF YES, describe size, type and location:
D. Are t ere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
A $._\4_Z1),
City of Northampton S ats a.P
Building Department C` rb but/D uewa "
212 Main Street Sewerl�Sept`i alab }
F
Room 100 WaIW�e1 Aval�a{-1
Northampton, MA 01060 TwoSetsofiStr c ura and$
phone 413-587.1240 Fax 413.587.1272 Plot%Sete P1ans � � � F
OtherSpectfji
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Prerty Address: This section to be,completed'by office' /�
Map Lot- Unit'
Zones ✓ ' Overlay District
Elm St. District CB District,-^
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
//��-,
Name int) Current Mailing Address:
Telephon•;
Signatur -- ��� �� �L ----— ------—
2.2 Authorized Aeent:
Name(Print) Curren; Mailing Address:
Signature Telep'ione
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 Y °s (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) va Check Number
This Section For Official Use Only
Building Permit Number: Date lssued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2002-0006
APPLICANT/CONTACT PERSON GERVAIS MARTHA S
ADDRESS/PHONE 591 KENNEDY RD
PROPERTY LOCATI
MAP 05 PARCEL 038 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: Install 168 square foot tool shed
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
INF,QAMATION 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 Commi
/ ZOO
Signature of Building O icial 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.
BP-2002-0006
COMMONWEALTH OF MASSACHUSETTS
is
CITY OF NORTHAMPTON
Lot: -001
Permit: Buildin
Category: BUILDING PERMIT
Permit# BP-2002-0006
Project# JS-2002-0008
Est. Cost: $3475.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 42078.96 Owner: DWYER WILLIAM&MAUREEN
Zoning:RR Applicant. DWYER WILLIAM & MAUREEN
AT. 591 KENNEDY RD
Applicant Address: Phone: Insurance:
591 KENNEDY RD (413) 587-0290 ()
LEEDSMA01053 ISSUED ON.7151010:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 168 SQ FT TOOL SHED
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 7/5/010:00:00 2209 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo