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cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/residence at:
(street city/staW2#)
do hereby certify, under the pains and penalties of perjury, 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 Compary/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compar y/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if neccs ry to incWc informiri:xi pertaining to all ooahndora)
(vJ I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowvcrs who employ pGZOm to do ruiolco act cordon Or itpau work on a dwelling of
not Moro than three units is which the bomoovmcr resides or oa the grounds apprrrtanar3 thado are oo(gcnmity oowidcrcd to be
employers under the worfccr'a oompc=tioa Act(GL152,=1(5)),application by a homeownis for a liccszsa cc PaR-a may cvidcaoc the
legal etahu of an employer under the Woriceez Compomatioa AcL
I undastaad th.t a copy of this its t—rd may be forwarded to the Dopartascnt of 1. uThi.1 Aocideot3 Office of Iamrraaoe foe thn
coverage vcrificatioa and that failure to secure covernga under scuioa 25A of MGL 152 can lead to the impOSihon Of arimin-+1 pia
eonustwS of a fine'of up to S1,500.00 and/cc imprison of tip to one year and civil pmaltia in the form of a Stop Work Order and a
fm of S 100.00 a day agtirat tae
For&Prim —caly
Permit Number
"`,"r� `/�"� Mao -- Lot#
,,
SiPA=of Licensee/Permittee e :
SECT�01! 1COT15` UCTIO�N 5EFt�/ICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Bolder: G eS-
0 13 CA y License Number
�c�, 5 . P Le s /2/0-5-3 Y-a.3-0A-
Address Expiration Date
lz� �� yl3
Signat re 67 Telephone
m Not Applicable (❑
Company Nailhe Registration Number
r—ow- F' 4,--a9-6�L
Address / Expiration Date
P,o Best 3 y L��r�S 'Al �/0,-2 —
Telephone `/l 3 S�y 117
SECTI6N,16-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....... Z' 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 buildinp,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 Signature
a
SECTIO. b wROPOSELO)MORK C ck fi a lic, b °r
x
New House ❑ Addition ❑ Replacement Windows Alteration(s) 25 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:1' r-Dam ke
Alteration of existing bedroom Yes—bl- No Adding new bedroom Yes 1/ No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑- Sheet❑
s'" i. �tltlit"on �oe"xastin �h�irs"in caim, leeEh"`' f 1,0"' g`'n
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 OWNE iAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS_'AGENTzORCONTRACTORAPPLIES FOR,BUILDING PERMIT
I, 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
I, I�f'4F
A.
,r �l�r as Owner/
hereby declar6 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
Signature of Own r/ - 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 'f 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 V
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:
� � n 92002 � Northampton
l5 Il g Department
LJ ` Main Street
JAN 1 oom 100
Northarrpton, MA 01060
87 240 Fax 413-587-1272
UT
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1-SITE INFORMATION
This secti''o orbeoompletedb" f c
1.1 Property Address: F
3 Al Ma le_ f, ivlap f of p
y
+^
one
Elo
Elm St'Distr"ict�` x:_ ° �
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
6 OX 3 % Lce1(s A4
Name(P ' t) Current Mailing Address:
//3— s�G—lei
C Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION:3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
com feted by ermit applicant
1. Building 4o DO a (a) Building Permit Fee
2. Electrical 0 0 (b) Estimated Total Cost of
Construction from 6 <
3. PlumbingGt 6 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Bias{ding Permit Number: a#e:Issued:
Signature:
;Buildipg Commissioner, nspector of Buildings Date
File#BP-2002-0642
APPLICANT/CONTACT PERSON Roger Clark
ADDRESS/PHONE P O Box 34 (413) 584-1170
PROPERTY LOCATION 23 NORTH MAPLE ST
MAP 17C PARCEL 219 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction:_REMODEL KITCHEN&BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 021310
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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 Commission
1_/` .0
Signature of Bui g OfficiaV f 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.
ST BP-2002.0642
GIs#: COMMONWEALTH OF MASSACHUSETTS
a :B1ock: 17C-219 CITY OF NORTHAMPTON
� Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0642
Project# JS-2002.1011
Est.Cost: $15200.00
Fee: $660.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Roger Clark 021310
Lot Size(sa.ft.): 1115 1.36 Owner: CLARK ROGER P
Zoning: GB Applicant: Roger Clark
AT. 23 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P 0 Box 34 (413) 584-1170
LEEDSMA01053 ISSUED ON:1114102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & BATHROOM
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 1/14/02 0:00:00 4462 $66eW
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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C WN V AL 'H OF NIA SAC iT ET TS
i iC [-1, OF MAMPT�l�i
Permit= Bu �di7t�
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Est Ccasi-1152K Uo
Cv�s Class. Contr License:
Lin GroYro. Roger Clark 021310
s f ELI OWMI, C OO.Ek P
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