17C-165 (3) v 1
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m DEPARTMENT OF BUILDr\TG INSPECTIONS
212 Main Street ' Municipal Building 'a,
Northampton, Mass. 01060 y 01
'WORKER'S COWENSA'RON INSURANCE AFFIDAVIT
--- (1i�ns.°rJpermi tree)
with a principal place of business/residence at:
(stTevt/city/st?teJzi n)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's compensation cover ge for my
employees working on dais job:
(Las- dnc^ Cotnp"EY) (Poky Number) ------- - (Ftipir:tion Date)
O I ester a sole proprietor, general contactor or homeowner (circle one) and have hired
the contractors listed below who have the following workers coupensation policies:
(-Namc of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaiiy/Policy Number) (Expiration Date)
(Name of Contractor) (Lasumn� Comp—my/Poky Numixr) Ex�irrtion Date)
(Name of Contractor) Jn_suruice Company/Policy Number) 0:xpiration Date)
(attach additioe:il slxct if nercnar:to ix}ucle infoemitioa pet-taining to all coc±mctor3)
( ) I atn 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 yt lc hcaxortincr3 who Gnploy perroai to do maintcuncr,co.s rac oo or repair`I'Ak on a d� g of
not more than tluro units in t,inch tIx hom,m ncr resides or on dh c grourx13 zppucterarzi thtcdo arc no(get-2lly cecJidcrrl to be
cmploytrs under the ocxr ssticn Act(GLI52-ss 1(5)),appLiczLnon by a homeowner for a l criisc a pcImil may cvidcnoc the
legal etahre of en omployer under tho Woricelt C.ompoosatiosr Act_
I undi r d thit a copy of thin ctatcmmi may bo forwarded to the Dctxi�of Indiut6al Accidcails'Oflioo of Inxuanco for tlm
coverage vcrificatioo and thst(allure to&carte covcrngo undx scctioa 25A of biGL 152 can lead to the imposition of avninal pca+ `::"
oowisting of a fine of up to S1,500.00 and/oc imprL-4x r,.'of up to orx ycjr and civil pcnaltia in dl form of a Stop W orV Ord-and a
fires of 5100.00 a day I&AI st mc_
Foe dcputnr-r uses"y
permit Number
A
l7rr
Signature of Liccnsc&P,-m-ittee Late-
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : --- —
License Number
Address Expiration Date
Signature Telephone
Si `Registered`°Home`Improvemerit Contractor ,,,, ,' , 3,„ , Not Applicable ❑
Company Name Registration Number
I
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...... ❑
Owner Eiemption
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 buildinjZ 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 SignaturJG
SECTION"5- DESCRIPTION OF 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:_�e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes --No
Plans Attached Roll ❑ - Sheet❑
6a. If"New" hoase°"'dffd"or addition'to existing housing, complete th'e following_
a. Use of building : One Family Two Family __Other
L). 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?
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
as Owner of the subject property
I
hereby authorize _ to act on
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 statements 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.
Print Name
Signa rut e of Owner/Agent Date
� C
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 tilled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side 1,: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin )
#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 ff
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 Status of�'e rnrt
:
Rijildin DP �
artment Curb°Ctf� ewa.. �r ..► 1 ° ,4,
Street §6124',k I Q
1 100 Watefy4wel�i Ava�ab fy 3
' Northhal MA 01060 Two bets of S�ructt ral arse ���
el 471., UT Fax 413-587.1272 Plot%Site Plans ]
Other Specify
A PI.ICq p, fT IiR, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION l - SITE INFORMATION
1.1 Property Address:
This section-to be completed by office,
Map Unit:
Zone OVerlay,District' _
Elm St. District C8 District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Narne(Print) Current MailinS Address.
_� ----- —'�--------- --- Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED OWN COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit a l ant
i. Building / �'J� (a) EUlfdln�> Permit Fee
611►1
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: Gib�, _ Date Issued
Signature:
Building Commissioner/Inspector`of Buildings Date
r
File#BP-2003-0280
APPLICANT/CONTACT PERSON ASHER DOROTHY M&CHARLES W SR
ADDRESS/PHONE 50 HIGH ST (413)586-4320 Q
PROPERTY LOCATION 50 HIGH ST
MAP 17C PARCEL 165 001 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 /�
Typeof Construction: DEMO 8 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
B_uil_ding Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With 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 Co ssion
Sig an ture 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.
r
. BP-2003-0280
GIS#: COMMONWEALTH OF MASSACHUSETTS
r lock:.17C 165 ,
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0280
Protect# JS-2003-0483
Est.Cost: $650.00
Fee: $10.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa. ft.): 14766.84 Owner: ASHER DOROTHY M&CHARLES W SR
zoniniz:URB Applicant: ASHER DOROTHY M & CHARLES W SR
AT: 50 HIGH ST
Applicant Address: Phone: Insurance:
50 HIGH ST (413) 586-4320 ()
FLORENCEMA01062 ISSUED ON.9126102 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO 8 X 10 S ED
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 Occupant Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/26/02 0:00:00 8711 $10.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo