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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '�..
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
A 11 L C�5�-
(licen-ue/permittee)
with a principal place of business/residence at:
none#) 0`-7Z`(cc7
(str=UCity/s 02ip)
d` /
o hereby certify, under the pains and penalties of penury, that:
am an employer providing the following worker's compensation coverage for my
employees working on this job:
V/ --
(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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insuran(e Comparr/policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addihoml shod ifn6oc= ry to include iafjxm oa pertaining to all oodradm)
( ) I am a sole proprietor and have no one worlang for me.
O I am a home owner performing all the work myself.
NOTE:please be await that whilo homcowncra who employ persow to do r+*aimm-ncc woe or repair work on a dwelling of
not more than throo tarts in which the homeowner ncsidcs oc oa the grounds appurtenant tbwcto arc oo(gccxralty oowak cd to be
employes under the work.ct's compcnulion Act(GL 1 52,=1(5)),application by a homeowner for a liccasc cc permit any evidcace the
legal ctatua of an employ«under the Wodccez compomatioa Ad.
r understand thit a copy of this statement may be forwnrded to tha Dtpwtnc�of Dial Ao6dmti Of$oe of Imuranoa for the
coverage verification and that failure to aec t coventgo tntder SeWoa 25A of MOL 152 can lad to tbd impos ion of-Mai penalties
consisting of a fine of up to S1,500.00 andlor i npriso�of up to one year and civil penalties in the form of a Stop Work Ord--and a
firm 013100.00 141Y agyinsl tnc.
/1 Fordgmtw� —only
permit Number
l/ �✓ wpb Lot#
r :. . Sr f Liccnsee/permi e
e� 'Al
SECT ON B�W CONSTRUCTION,
ER",
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : `�► Ir �� l
License Numbed
0�2
Address �� Expiration Date
4.
cG ? 7 -7
Signature Telephone
r_ v ;gin n r a � , �
Not Applicable ❑
Ak Co
Company Name Registration Number
Address Expiration Date/
rc,I. Telephone &2 —/-24 7
SECTION i10-.WORKERS' COMPENSATION INSURANCE AFFIDAVIT kM.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 permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
om " n6 pt 11� ,n
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 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
SECTION S:DESC�F21PTIGN bFiPR`OPOSEDa £OR' tctieclima I.a 'iicable
vet
�?. -„.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: LA
Alteration of existing bedroom Yes No Adding new bedroom Yes No
`�
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a If New t oilse and oir addit on to ez'is 1ii_k2 oi-Nin'M,,,t iggamij6ilowin :
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„ ,OWNEWAUT RIZATION -TO BE COMPLETED WHEN
DWNER AGENT OR?. QR APPLIES;-FOR`BIJILDING PERMIT
as Owner of the subject props
hereby authorize to a�
my behalf, in all matters relative to work luthorized by this building permit application.
Signature of Owner Date
I, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pain and penalties of perjury.
Print Name
Signature of Owner/Agent Date
1
f
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 S aces
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:
I
City of Northam FE4
Building Depart n i
212 Main Stre t
Room 100 a �}
Northampton, MAO ;
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed ffice„
1.1 Property Address: �8,
Map Lots nit
Zone- Over,R is#r�ct
lts�c l'� 1r n A
Elm St. District CB Distract"'
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record-
F�
Name(Print Current Mailing Ad ss:
, < \ .5A
ft�' Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: ®LQi
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS`
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit a plicant
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) Check Number
This Section For Official Use Only_
Building Permit Number. Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0693
APPLICANT/CONTACT PERSON MYCO CONSTRUCTION
ADDRESS/PHONE 288 EAST ST (413)467-7747
PROPERTY LOCATION 91 GROVE ST
MAP 38 PARCEL 048 001 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: RENOVATE KITCHEN(COUNTERS&FLOOR) ,REPAIR PORCH&SILLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 057647
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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 Co ion
S 2 Z_
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
BP-2002-0693
GIS#: COMMONWEALTH OF MASSACHUSETTS
' " iyrt 3s_048 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0693
Project# JS-2002-1109
Est.Cost: $13638.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MYCO CONSTRUCTION 057647
Lot Size(sq.ft.): 65340.00 Owner: NORTHAMPTON CITY OF
Zoning.URB Applicant: MYCO CONSTRUCTION
AT. 91 GROVE ST
Applicant Address: Phone: Insurance:
288 EAST ST (413) 467-7747 Workers
Compensation
GRANBYMA01033 ISSUED ON:216102 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN (COUNTERS & FLOOR) ,
REPAIR PORCH & SILLS
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 2/6/02 0:00:00 0 $0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo