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cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street w Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee}
with a principal place of business/residence at:
(phone#)_
(city/�tat�ap)
do hereby certify, under the pains and penalties of pegury, 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)
�) a sole proprietor, general contractor or homeowner (circle one) and have hired
`tile contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy 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) (Ex-l)iration Date)
(attach additional slice if nxczz to inchrdc information pertaining to all cca7adors)
( I am a sole proprietor and have no one'w' orking for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whi]o homeowver3 who clay persons to do mxaAcami r wnt u't oo or repair work on a dwelling of
WE man than throo units in which the homtowwr resides or on tho g ouo appu�thereo arc not&camafly comidatd to be
cmploy+aa undcr the warktelpcasation Act(GL152,"1(5)�application by a homcowna far a Ecc=a permit may cvidcooc the
legal status of an omployor under the Wockeez Comp. ation Act
I undentaad tbst a copy of this s2atcmcat may bo forwarded to dK Dcpartnmf of Indritne!Acci cn&Ofboe of Imiuinco for the
coverage va ification and that failure to axons covcrago uodcr stetson 25A of MGL 152 can lead to tho imposition of criminal pcnaWcs
oomisting of a fmo'of up to S 1,500.00 andlor imprison of up to one ytar and civil penalties in the form of a Stop Work.Onda and a
fmo of 5100.00 t day tgniwt mc.
For&ga�use only
Permit Number
Map;t Lot�
Si of Licensee/Permittce e
SECTlON18'-,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : r / `7/� �
License Number
J ,
01�r
AdAd r Expiration Date
Sig at re Telephone
Re # el�' rim m royementC4nt actor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. c. 152, § 25'C(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 Signatu ire "°`G��
SECTION 5 DESCRIPTION°.°OF PROPOSED WORK(check all`applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement --Yes No
Plans Attached Roll 0 - Sheet❑
fa 'If�Newhouse'° a�'id °oraii"tlition`fo'exi'sting�housing.:comple"te_tlie�foll`owin�•
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,-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT'OR CONTRACTOR APPLIES FOR BUILDING''PERMIT
I. G as Owner of the subject property
hereby authorize to act on
my behalf in all matters rela '�tork author ed by this building permit application.
Signature of'Owner Date
1. as Owner/Authorized Agent
hereby decl that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge qhd belief.
Signed under the pains and penalties of perjury.
Prin ame
LS�iignat e 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
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:
City of Northampton t
ing Department
[D�
E Q U 2 Main Street 5 r
Room 100 a
Ll
f
N t mpton, MA 01060 a t~sa
i y`f phone241 -1240 Fax 413-587-1272 Pa �stt _
AVOTMkMAW1iMaONSTR CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION_ 1 -SITE INFORMATION
This section -to,,be�completed W"off
1.1 Property Address: RR _ _ a
Map' Lot
Zone Oyerlay DIstrtct < fi
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record-
Name(Print) Current Mailing Address:
Telephone
Signature —
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Sig ure Telephone _
SEC ION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
—completed by ermit applicant
1. Building r (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
.This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2003-0251
GIS#: COMMONWEALTH OF MASSACHUSETTS
k � CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0251
Project# JS-2003-0442
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: James Roberts 117154
Lot Size(sq.ft.): 4704.48 Owner: KASPER MICHAEL F&MARY LUCE
Zoning:URB Applicant: James Roberts
AT: 106 HIGH ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:9111102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 9/11/02 0:00:00 1625 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo