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17C-305 (3) Wo ¢p 1. r r tt i i 4'C1iAMP�. (rzt� laf 'Wart4aillvfav aB �lxsat:chnsrtfs m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFMAVIT (Iicensee/permittee} with a principal place of business/residence at: /!WA C q©2 1(phone#) 5�F G ' Try (streeUci ty/st atria p) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following workers compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Dale) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) r. (Name of Contractor) (insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (atIaot,additioml sheet ifnooasary to inetude information pertaining to all ooatrt d ) ,��4am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homeowners who employ pc=m to do m*in*m&^c,,conexietiou or rzpaff work on a dwelling of not mode than throe mutt is which the hotmowncr residw or on rho grounds appurtenarrt thetdo art not gexxrally oonridercd to be employers under the me e's oamp= 4oa Act(GL152,ss 1(5)),application by a homeown r fora license or permit may evidmoe the legal ctatru of an w*loyer under the Worker's Compensation Act I understand dtud a oopy of thin statement may be forwarded to the Dopartmccd of Industrial Aoadeaae Oftioo of lasurwce for the coverage verification and that failum to secure eovetago tender section 25A of MGL 152 can lead to tba imposition of criminal pantries oomistixtg of a fine of up to 51,500.00 andror'impriso of up to one year end civil penattia in the form of a Stop Work Order and a firm of S 100.00 a day against tae. For d uao onty Permit Number Map# Lot# Signature Licensee/Permittee Lime SECTION 8'-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Wgjk Not Applicable ❑ Company Name Registration Number _S-4 /1l O CoIC S C 7 A,0 16, -x Address Exp iirat on C5ate AV A O/D-<-t 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...... ❑ 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 building Permit. As acting Construction Supervisor your presence on the fob 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 -D9$CRJPTJNM,P O K h` c all` li abl New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other"[ ] Brief Description of Proposed Work: ou u— Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ u 1012: 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-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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 Jo as Owner Au ho=Agent hereby declare that the statements and information on the foregoing application are true and accurate, to t y knowledge and belief. Signed under the pains and penalties of perjury. Print Name nature of Own ent Date Section 4. ALL INFORMATION MIDST 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 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 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 1.1 Property Address: �J- S C�11 r- SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: L L /As C-4 Name(Print) Current Mailin Address: I --�-a 7 Telephone Signature 2.2 Authorized Agent: A,mecve- Name(Print) Current Mailing Address: 4ure Telephone M-ON,'3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building (a) Building Permit Fee P 2. Electrical (b)Estimated Total Cost of Construction from 6'' 3. Plumbing Sullding: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 y { 125 CHESTNUT ST BP-2001-0424 G1S#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-305 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofm BUILDING PERMIT Permit# BP-2001-0424 Project# JS-2001-0722 Est.Cost: $3253.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: John Corbett 104000 Lot Size(sq. ft.): 24262.92 Owner: HEALY BEVERLY A Zoning:URB Applicant: John Corbett AT. 125 CHESTNUT ST Applicant Address: Phone: Insurance: 56 Dimock St (413) 584-5807 LEEDSMA01053 ISSUED ON.10123100 0:00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING 1 LAYER 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 signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/23/00 0:00:00 930 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo