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m DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORK-EIR'S CONMENSATION INSURANCE AFFAMAVrr
(1i censee/permi ttee)
with a principal place of business/residence at:
(phone#)
(&U=Ucity/stalrJrip)
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 tlm job:
(Insurance Company) (Policy Number) (Expimtion Date)
O 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 Compauy/Policy Number) (Expiration Date)
(Name of Conti-actor) GDSuranoe Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiccul s+sect ifn6oca+ry to incKude iafocmirioo pataiaing So ell oo�radots)
O 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 that wtulc homcowvcta who cmplay pczo to do mabjr•,• c�r,co'- c ioe ur repair work on n dwelling of
not more than throe unto in wfr ch tt)e housoowncr rrsidcs oc oa the gra n}y appurtenant thacto a t not grnczlly com dcrcd to be
cmploycra under the work %onmpc=ation Act(GL152,sa l(5)�applicaticn by n homoown r for a l crasc cc permit may cvidcnoc the
legzl rtII Of An amptoyer under tho Workeet Compemat AcL
I understand thst a copy of this rtatemeat may bo forwurded to tho Dopartmcut of Inrfii3bial Aca&n&Of 5-of 105ur�co for tho
coverage venficatioo and that failure to secure coverage under scctioa 25A of MGL 152 can lead to the impos ou of criminal penalties
oomisting of a fine of up to S 1,500.00 andloe itnprisonmcrd of up to one year and civil p,.,a is in the form of a Stop work Ord--and a
fum of S 100.00 a day a&rinst tnc_
For dept taroW use only
permit Number
Map 1 Lot#
err Signature of Licensee/Permittce e
SECTION 8C�NSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �r(f Y 1 �� �+� �r. o s 3 '3
License Number
PO Pool y a G -C I d- , M 14 0 3
Address Expiration Date
_.
0, QA Q1
Tele ho
-- gnature P
4eL stereii`e'Abrne mprQvemen�'Co Not Applicable 0
l 0 0001
Company Name Registration Num er
C-
Add.qess , Expiration Date
lJ � �-s `l t4A Telephone SI&-1 J�J7/k✓
L
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 affic
will result in the denial of the issuance of e 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)famil',
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 they:
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
kil
SECTIONS D 5C
P1
016 ch c`kall a hcable
�.•el,.1N,.-Sa°q" dRN'u nP*.ntula+•rT° d a�- .,p"mBUr S"t'-+.«"+,,NAf'+b'Y� aS�PY.�AxS4 raNiAn..n,». „iiAZ.Y,R�. ,R+d....fio K, f�n.LA�rk4�r+2 3...- ,MNC:.7•- .
b,*� k s.»k .—Y�:�.;U.�� ?tk 3i*i<,iB7.ri''Pr;,. .' 37_.v ;.I1U'N:r:,:,:�1,
New House ❑ Addition ❑ Replacemen endows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed WorEZrV1S5la 1)1 6G Vi V1 rC QJ'giV{'Y)(4 n ()('—J�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
ca�If�N''dW, OUSU a&611% dition Rtb ex'rstingfiaiasing complete tt e:follouvin
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 .OW N,ER:AUTHORIZATION -TO.BE COMPLETED WHEN
OWNERS AGENT OR=.CONTRACTOR,APPLIES FOR'BUILD]NG PERMIT
1. as Owner of the subject prope
hereby authorize to ac
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 the statements an information on the-#e application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
kc4ujre pr(,,i Ear ►M S�'
Print Name — ^—�
�a_ ,
Sign u e of Owner/Agent Date
y
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:
IL
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 +~ s
phone 413-587-1240 Fax 413-587-1272 Po .Ste
Grp
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This sectio Ito begcompleted b: fflce
1.1 Property Address: z
Li
Cf�, Map 'Lotr Onto
Zone OuerlayDistr�ct z
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address.. O
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: a
9/ 3 5gy-37/,C
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 =(1 + 2 + 3 + 4 + 5) f S Check Number
This Section For Official Use Only
Building Permit'--Number. -Date Issued:
Signature:
BuiloingCommissioner/Inspectorof;Bulldings,.� _ Date
24 WILDER PL BP-2002-0581
GIS#: COMMONWEALTH OF MASSACHUSETTS
ay:Blogk: 17C- 195 CITY OF NORTHAMPTON
Lot:-001
Permit: Q u i l d bg
Category:windows replaced BUILDING PERMIT
Permit# BP-2002-0581
Project# JS-2002-0910
Est.Cost: $615.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
UseGroun: THE JUBB CO INC 100001
Lot Size(sq. ft.): 4922.28 Owner: HAYNES CHRISTOPHER A&ANNE
Zoning.URB Applicant: THE J U B B CO INC
AT. 24 WILDER PL
Applicant Address: Phone: Insurance:
P O Box 429 (413) 772-6217 Workers
Compensation
GREENFIELDMA01302 ISSUED ON:12113101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 12/13/010:00:00 5316 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo