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17C-285 (3) ��ttnMpTO ZO a - a6 f�asanrEtnsrtla DEPARTMENT OF BUILDD,TG INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFMAVTT (licenseeJpermittec) with a principal place of business/residence at: (phor)e#) (Str�{/ci ty/state zip) do hereby certify, under the pains and penalties of perjury, chat: ( ) I am an employer providing the following workers compensation coverage for my employees working on this job. (lnsu=ce� Company) (Polio Nu=mber) -- — (Expiration Date) I = a sole proprietor, general contractor or h meowner circle one) and have hired the contractors listed below who have the follow,.tl s compensation policies: S,eioeS 0utocex 4cceAj-t- �!✓e14�bH/,e s . A,/,fi K'�� .r//7 , -AM- (Name of Contractor) (IncuraTyL.-."nipany/Policy Nurnbcr) (Expiration Date) (Name of Contractor) (Insurancz Company/PoLcy Number) (Expiration Date) (Name of Contractor) (Insurance Compmy/Pokcy Numtk.r) (F-\piration Date) (Name of Contractor) (Insurance col-Lipany/Policy Number) ! xpiradon Date) (attach additioml.'-,-rt iFncccstary to include infortnatioa pertaiuing to all acion) 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 await that wAiilo homcovncn who cmplay pcaoru to&anaiat ..,n oaasiruG oa er repair wuvk ou a dwttLmg of not moeo than threo uaits in Which the homeowner maiden oc oa the grounc}s z?purt,-nu thereto arc not gti)aany cociidcrcd to be catploytra undo tho work x oxap=sAtioa Act(GL152,=1(5)),appUcatian by n homeow=for a license cc permit may evidence the legal"2bU of an ernployet under the WosiceC's Compomation AcL I understand th,t a copy of this rtd=cut may bo fbswardad to tho Dcpa�of Indw hill Ao6d1;a&Ofbi of LavLu >co for tho coverage vaifiadion and that failure to acatre covct a under---joa 25A of MOL 152 can Icad to tba imposition of criminal pcualt:ca ooasistiag of a fine'of up to S 1,500.00 and/or imprisonmaii of up to one year and civil pena16ct in the form of a Stop Wotic Ordc and a fain of 5100.00 a day against the For dcputnrmisl use only — y / Permit Number 3�/S J c3 �,Z tvfal Lot# gn iawm of Li ermittce e . • r SECTION 8 .CONSTRUCTION SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ i Name of License Holder License Number Address Expiration Date i Signature Telephone a. -lm.._a. ^t. ' "�- .,• Not A PP l l c a b l e ❑RV M i Nx o Company Name Registration Number Address Expiration Date 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ MIE ptW 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 s ructures accessory to such use and/or farm structures.Anerson 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 jc,b 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(Workea 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 �y—s� _ SECTION'5 DI:SCRIPTI6N,OF3 PROPOSED IWO RK(check alJ applicable) N .. ,< New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] rief Description of Proposed Work: /-'—" o/D SL L°P �✓/� l���Fr�B z�, S� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet o 6a, If�New�Fofise�a�tid or�adtl`ttion to° ezistingho'�rsing;°�complete�the following: 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? i ype 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 r OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject propert,, hereby authorize ___ to act on 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 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. rint Name Date ignature of Ow er/Agent 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 45 Side L: R: L: R:,511/ Rear Building Height Bldg. Square Footage % Open Space Footage % U (Lot area minus bldg&paved parking) #of Parking Spaces Filr_1 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: .� t o orthampton o Bu i Department MAR 1 8 2002 ! ain Street e " Ro m 100 " �� �,, �. Si damp on, MA 01060 is c,t:. i,r ,, ,,�,Ilv NORIPA fib'h,A 40 Fax 413-587-1272 �o Ot�erSpe�rfy APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by offl', x 1.1 Property Address: 7, Jz W3 3� t' Y' MapLot �ii} � 'ate 0 Zone - Overlay District Elm St. District; CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r `c � 2 G t %/ g o a l/ - Name(Print) Current Mailing Address: Telephone Signature �y� - 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 comple ted b ermit applicant 1. Building Al® d 6- 66 (a) Building Permit Fee 2. i'ectrical (h) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) ��n c, t� rotA 5. Fire Protection al 3 Lf�5 °-Z 6. Total = (1 + 2 + 3 + 4 + 5) Check Number d This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date f r X fA R -D 3 File#BP-2002-0783 APPLICANT/CONTACT PERSON HICKSON DAVID J&DARLENE J ADDRESS/PHONE 32 LILLY ST (413)586-3435 Q PROPERTY LOCATION 32 LILLY ST MAP 17C PARCEL 285 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid _ Typeof Construction: REPLACE SHED W/12 X 24 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Commission Signature of Building OfficiZ 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. 32 LILLY ST BP-2002-0783 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-285 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category. shed BUILDING PERMIT Permit# BP-2002-0783 Project# JS-2002-1303 Est. Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sg. ft.): 9234.72 Owner: HICKSON DAVID J&DARLENE J Zoning:URB Applicant: HICKSON DAVID J & DARLENE J AT. 32 LILLY ST Applicant Address: Phone: Insurance: 32 LILLY ST (413) 586-3435 (� FLORENCEMA01062 ISSUED ON:3121102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE SHED W/12 X 24 SHED 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 3/21/02 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo - # �, a� {..4} I f I ..: 1 y�' I I � ; :. '� � � -I ' { � i 32 LILLY ST BP-2002-0783 GIs#: COMMONWEALTH OF MASSACHUSETTS Mav Block- 17C-285 CITY OF NORTHAMPTON X001 Permit: Btaifdini Catesory:shed BUILDIN9 Pest# BP-20Q2-4783 Project# JS-2© 2.1343 Est.Cost:$4000.00, Fee:$25.00 PERMISSION IS HERESY GRANTED TO: Const.Class: Contractor: License: Use Grouv; Lot Swint-l 9234.72 Qwner IiIQMN DAVID J&DARLENE J zoning=ul 4110 C t: 1-�„ K C?N DAVID J &i DARLENE J J 32 L1LuY ST Al gagant jA ess:` Phi Insu 32 LILLY ST _. (413)586-3135 t) FLC}t EI�tCEt fA( i }52 I SUER DN:3121102 07JO O TOPE FORS f THE FOLZ.OWVV ar ORK.REPLACE''SHED W/12 X 24 SHED POST THIS C O I VISIB FROM TH STREET Inspector of Plumbing Inspector of wiring D.-P.W. Building Inspector Underground: Service: Meter: Footings. Rough: Rough. House# Foundation: Driveway Final: Final: Ant.. _ Rough Frame: Gas: Fire Deuartmmn t Fireplace/Ch muey: Rough: OIL, Insulation: Final: Smioke: Final: THIS PEMT MAY'11 REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES,AND REGULA'F ONS, S n tur t # e: Fee ha: R t N,g: Pate Paid: ,9Mk No A-MU LtV. Building 3/21(!02 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building C&Mtpi t-Anthony Patllo