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t DEP TMENT OF BUILDING INSPECTIONS
212 ain Street ' Municipal Building
`Northampton, Mass.' 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Licens permittee)
with a principal place of business/residence at:
6je r 1�04Nc,,nn t�'W (phone#) (�//3 SFf y- JZzy
(strc-/city ap)
do hereby certify, under the pains and penalties of perjury, that:
(✓S I am an employer providing the following worker's compensatiion coverage for my
employees working on this job:
At #Aeo ce, r>yt,t� c Cm t,j G'13 3c'I 31`b p s '7 ' 1 - 91
(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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Dace)
(Name of Contractor) (Insurance Comparry/Policy Numbu) (Expiration Dale)
(Name of Contractor) (Insurance Compauy/Policy Numbu) (Expiration Date)
(attach additioml sheet ifneoc=ry to iadudc iafbrm oa pertaining to all oo�cton)
( ) 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 awam that wbilo bomorn,vcn,wfio employ persom to do,,••;m-,, = wos:rutioa,or ripair work on a d vdling of
not more thaa throe units is which the bomoawocr mid=or on the grounds rppurtcnuII tb,r,"arc oa gcxrally wwWacd to be
employers under the wockC compessatica Act(GL152,=1(5)),application by a hoa=wn r for a&=x cc permit may-id—the
legal stslva of an employer under tho Wockcea C aVew iioa AGL
1 undmvAi sd data copy of this rritcmcnt may be forwardad to rho Dopaamccd of Industrial Acdd�OffiOe of 10%X1DM for tea
coverage vrrifiadion aid that failure to secure covcngo umdcr soe oa 25A of MOL 132 can led to tbtt imporrhon of ai-I-A pcaalacv
oomut ing of a-fim ofup to S1,S00.00 andfor imprnoamcr d of tip to toe yr r and Ova pea Ncs in the form of a Sep Wosic Order and a
floe of 5100.00 a day agaiasl M
For use CWlr
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. Tel.No. Sgt" ZLy Alterations
NORTHAMPTON, MASS. //3 19 71 Additions
a APPLICATION FOR PERMIT TO ALTER Repair
Garage
1. Location Ile"--I C k Lot No.
/
r JC/Cyan( /inch Address G3 IV/A
2. Owner s name
3. Builder's name X*I' `1a15 ISM'' o"'') Address 3°77 51
Mass.Construction Supervisor's License No. CS 0'73`/5 y Expiration Date
4. Addition ® 1
S. Alteration 2 Qoo rw �.� / ii o r Df/ece /4,- u/, I/
6. New Porch
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating
11. Distance to lot lines
12. Type of roof
13. Siding house
14. Estimated cost:;
0 05, 006. 00 The undersigned certifies that the above statements are we to the best of his
knowledge and belief.
Signature of responsible appiitant
Remarks
10. Do any signs exist on the property? YES ✓ NO
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
11. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This col— to be filled in
by the Banding Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L• R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paced parking)
# of Parking spaces
f of Loading Docks
Fill:
(v01-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
DATE: /0//,3/y�_ A.PPLICANT's SIGNATURE -5;ez'e 1.
NOTE: Issuanoe of a zoning permit does not relieve an applioants burden to oomply wlt4 .4111
zoning requirements and obtain all required permits from the Board of Health. Conservation
Commission, Department of Publio Works and other applionbla permit granting authorities.
FILE #
OCT 1 31999 :4'j
File No CYO 9�
DEFT of BUILDIN3 1
_ t' NING PERMIT APPLICATION (§10 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: �i c `i -, -, 'Y"''Li/:�
Address: �✓"�l b�lij'1 /!/Oi�yG��►�.d -1 // Telephone: 22- -L C 3 7
2. Owner of Property: 'elcx_a/'--/ c�C
Address: r/o 3 Mti 1� 5f fw �Zorw*rc< Telephone: /771
3. Status of Applicant: Owner v"' Contract Purchaser Lessee
Other(explain):
4. Job Location: 6-5
Parcel Id: Zoning Map# ZZ, Parcel# p)05 District(s):
(TO 6E FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property �✓JSu/��tct �Jus��t�5
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
7. Attached Plans: Sketch Plan _�Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
8. Has a Special PermitNadance/Finding ever been issued for/on the site?
NO DON'T KNOW- z 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#
9. 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:
(FORM CONTINUES ON OTHER SIDE)
File#BP-2000-0391
APPLICANT/CONTACT PERSON Richard Ahlstrom
ADDRESS/PHONE 36 Service Center (413)584-2180
PROPERTY LOCATION 63 MAIN ST
MAP 17C PARCEL 205 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_yueof Construction• CONSTRUCT 2 DOORWAYS INTO INTERIOR OFFICE PARTITION WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 009498
3 sets of Plans/Plot Plan
T OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved 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 'ss'
Signature ding 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.
63 MAIN ST BP-2000-0391
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 17C-205 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-0391
Project# JS-2000-0669
Est.Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Richard Ahlstrom 009498
Lot Size(sg.ft.): 14157.00 Owner: FINCK RICHARD W TRUSTEE
Zoning: GB Applicant: Richard Ahlstrom
AT. 63 MAIN ST
Applicant Address: Phone: Insurance:
36 Service Center (413) 584-2180 Workers Compensation
NORTHAMPTON 01060 ISSUED ON.•lo/19/1999 o:oo:oo
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 DOORWAYS INTO INTERIOR OFFICE
PARTITION WALLS
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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/19/1999 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
63 MAIN ST BP-2000-0391
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-205 CITY OF NORTHAMPTON
Lot:-001
Permit: Buik na
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-0391
Project# JS-2000-0669
Est.Cost:$5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GrgW: Richard Ahistrom 009498
Lot Size(ss .ft.) 1415 7.00 Owner: FINCK RICHARD W TRUSTEE
Zoning:GB Applicant: Richard Ahlstrom
AT.• 63 MAIN ST
Applicant Address: Phone: Insurance.
36 Service Center (413) 584-2180 Workers Compensation
NORTHAMPTON 01060 ISSUED ON.1011911999 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2 DOORWAYS INTO INTERIOR OFFICE
PARTITION WALLS
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: /O�11�Q9�,f� 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 gy NORT O ON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate i nature•
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/19/1999 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo