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23D-123 (8) Is FED 9 OEPT OF BUILDING INSP IONS NORTHAMPTON,MA 1060 i 1 I I 41- � I � I D Q W Vii I V I $ B �lassacliasctta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'a Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (li censer/perrni ttee) , with a principal place of business/residence at: (phone#) (street city/stafdzip) do hereby certify, under the pains and penalties of pegury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees working 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 Company/PoLicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach-kH6oasl shed if necessary to include infwmation pertminin6 to all 000tnn ) ( ) I 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 thst while homcown=who emplay persons to do mx__;__T wY ooastr dioa or repair work ou a dwclliag of not more than throe units is which the homeowner resides a on the Vvuads apNdeasurd Ibm;to are not generally oomidemd to be employers under the workers oompeaulion Act(GL152,ss 1(5))�,application by a homeowner for a license or permit may evidence ttte legal status of as employer under the Workees Compamatiou Act I uadentaad tint a copy of thin uatemeat may be forwarded to the Departa cei of lades rial Aed&a&Ofoe of 11mra0ee for the coverage verification And that failu m to secure coverage under secuoa 25A of MGL 152 an lead to the iatpos—of criminal penalties oomLaing of a fine of up to S1,500.00 and lor knNisonmert of up to one year and civil peaahia in the form of a Stop We&Order and a firm of 5100.00 a day against me. F Signab=of Licrosee/Permittee Date StCT 6WO•CONSTRUCTION'SERYlCES Licensed Construction rvisor: Not Applicable ❑ Name of License Holder: ' ` License Number Address Expir, ion Date AIM Signat Tele hone Not Applicable ❑ Company Name Registration Number G T Address Expiration Date 13 &���S:L T 0- ' CTIQN,�Q 00RKERS 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. (ned Affidavit Attached Yes....... ❑ No...... ❑ F 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 J 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 P ' ck I I' ' be le- New House ❑ Addition ❑ Replacement Windows Alteration(s) IV Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] firiej,Pescription of Proposed Work: F"V1 /S A Z C 6 a k- — f 'Add d R- Pj�e'r Uw� ti S t G�t vk t?w} X1 s� Alteration of existing bedroom Y� No ing nWbedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ q am a. Use of building: One Family Two Family Other b. Number of rooms in each family uhit: 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? 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 s car©la 7a OWNER APTHORIXATION -TO BE CQMPLET90 WHEN Q `Nisi A0EN"If0 CaNTRAGTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby declare that th sta ements aM information on the foregoing application are true and accurate, to the best of my knowledge and belief. igned under the pains and penalti of perjury._Vn Print Name Signatur f 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: rL L, Q kii o thampton ui g epartment U' FEB 9 M21 n Street I 100 Northa pt , MA 01060 DEPTO�#04 -12 Fax 413-587-1272 NOR, ON MA 01060 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIdN'1 SfYE °IhfF01;MATION 1.1 Property Address: ; x �In 3 R r SECTION 2-,PROPERTY OWNERSHI-P/AUTHORIZED AGENT 2.1 Owat r of Record f � d 3 Name(Pr' ) ��✓' i' r` /�� ' ..an ure 2.2 Authorized Agent: /° lL Name(Print Aw Signat e SECTION 3- 6TIMATED 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 Co rltruction from ,6 3. Plumbing Building�Permit Fee r 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 +3 +4 + 5) Check Number This Section For Official Use Only Buiid4rig'Permit Number. Date Issued; ...;nature Building Cornmissioner/Inspector of Buildings Date, File#BP-2001-0684 APPLICANT/CONTACT PERSON COOK BENTON D ADDRESS/PHONE 13 GROVE ST (413)268-3265 Q PROPERTY LOCATION 184 FEDERAL ST MAP 23D PARCEL 123 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: FINISH ATTIC(2 BEDROOMS MATH&INTERIOR PARTITIONS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildiniz Plans Included: Owner/Statement or License 049209 3 sets of Plans/Plot Plan THE FPk<bWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: pproved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Co ission _Permit from CB Architecture Committee Signature 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. 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