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17C-230 (2) .'� 1 I, Ii I ` 4C11AMP�0 B $ Grxi� of Nart4ailIpftltt 8 6 �lz<s:acilttsctts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT flAw Kffi5 Roo c 1186 (licenserJpermittee) with a principal place of business/resideuce at: 6 0 ITA(phone#) � (str=t/city 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: As) 6n L (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: (No-me of Contractor) (Insu=ce Company/Policy Numbcr) (Expiration Date) If (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 additioail sheet if necessary to include information pertaining to all oomradors) ( ) I am a sole proprietor and have no one worldng for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while hoaxowrxn who employ pazom to do tna *r a con�vczioa or repair work on a dwelling of not mote than throe unite is which the homeowner resides of on the Voua is appurtcnnnt thereto are floe generally ooaridered to be eruploycra under the wocic,cex ocampcnsatioa Act(GL152,ss 1(5)),application by a bomeowna for a license or permit may cvidcaoo the legal status of an employer under the Worko s compema ion Act_ I understand that a copy of thu uat—t may be forwarded to the Dgxrm,m2 of Industrial Accident;Of .of Insuranoa for the coverage verification and that failure to scare coverage under section,25A of MGL 152 as Icad to the imposition of-mia+l penalties coausting of a fine of up to S 1,500.00 and/or imp¢isonmcat of up to one year and civil penalties in the form of a Stop Work Ord--and a find o13100.00 a day against me. Fa d rp�uao en1Y ,? permit Number V lviap# I.Ut# gnahtre Afcensee/Permittee mat SECTIbN 8 CaISI RISC ION;5ERVICES 8 3. Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone vementContracto " 7� Not Applicable O o bany Name gi Res ration lAumber P In 4(o- ? i:� l� Address Ex ira ion ate 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 affid: will result in the denial of the issuance of the building permi . Signed Affidavit Attached Yes....... ❑ No...... The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili 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 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 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 persom 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 SfCTI'OI�C.i DESCR P.I f��D PR a POSED WORK".check 61va licable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing / Or Doors ❑ Accessory Bldg. 11 Demolitionb New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work:--,qQ 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 Never 96 M" n rof,''dditi6n'td"d Mflffiflf using..COmp""1ete'kth6J611 W"i„ 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 . 1. Septic Tank City Sewer Private well City water Supply SECTION 7a OW,NER AUTHORIZATION .TO4BE°COMPLETED WHEN QWNERS AGENT OR CONTRACTOR ApPLIS I`4R BUILnING PERMIT as Owner of the subject prope r hereby authorize to ac my behalf, in all matter relati work authorized Xthis building permit application. fE�S d L Signatur Ovane Date AA 1. asr/Authorized Agent hereby,declare tha the statements and information on the foregoing application are true and accurtiff, to the best of my knowledge and belief. Signed under the pains.and penalties of perjury, hAu) Print e NLO Sig at e o n'f I Date I � 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 O f 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 Registr f 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:6_V—M ,S I e,-(S s 16143' D. Are th e any proposed changes to or additions of signs intended for the property ?YES No ; IF YES, describe size, type and location: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413.587-1272 I'lotll e P O� e APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed uy office; 1.1 Property AdJddrress: /n� z �r 1 h Map V Lot Unit T CIO Qe) I1) b Zone Otierlay District Elm St.District CB District'' SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner f Record: rL w 3© lb ;yle-, ac,0 Names Current Mailing Address: Telephone 'ri2 Signat e v `l J 2.2 Authorized Agent: UJ�ilG --�Q� 1 I�6 9 0 & `� C4 7 S� H' 0-0 N0sinature Print Current Mailing'Address: ? 7q � Uq 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 b 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: Date Issued: Signature il Bu din g Commissioner/Inspector of Buildings Date i3=NORTH MAPLE ST' BP-2002-0755 GIS#: COMMONWEALTH OF MASSACHUSETTS a :Block: 17C-230 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category roofing BUILDING PERMIT Permit# BP-2002-0755 Project# JS-2002-1251 Est. Cost: $17500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HAWKI NS ROOFING 113957 Lot Size(sc. ft.): 27878.40 Owner: ARNOLD WILLIAM zoning: Sl Applicant: HAWKI NS ROOFING AT. 30 NORTH MAPLE ST Applicant Address: Phone: Insurance: P O BOX 107 (413) 774-6834 Workers Compensation GREENFIELDMA01302 ISSUED ON:317102 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 3/7/02 0:00:00 10539 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo