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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSAI-TON INSURANCE AFFDDAVTr
(licensee/permitree}
with a principal place of business/residence at:
(phone#,
(streei/city/statdzip)
do hereby certify, under the pains and penalties of pedury, that:
( ) I am an employer providing the following worker's 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 worker's compensation policies:
(Name of Contractor) (insurance Courparny/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (E)piration Date)
(anaeh additioml sheet if necessary to include information pertaining to all ooatmc r )
( ) 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 awun that while homeowacts who employ pc=m to do maimmamcq constvdioa or repair work on a dwelling of
not more than three units is which the homeowner resides or on the grounds appurtenant thereto are not geoeraky oowidat:d to be
emplayaa under the worker's comprasalion Act(GL152,ss 1(5)),application by a homeowner for a license or pound may evidc=the,
legal status of an employer under the Wodceea Compemation AcL
I undetstaad that a copy of thin datemmt may be foe warded to the Department of Indushial Aoeidents'Oboe of Iawranoe for the
coverage verification and that kUm+e to secure covetago under section 25A of MGL 152 can kid to the imposition of mmiaal per Wcs
oomisting of a 4iae of up to$1,500.00 andlor imprisomnerd of up to one year and civil penalties in the form of a Stop Work Order and a
fim of 5100.00 a day against tee
For dep=tW, W use oalY
PeTmit Number
Map# Lot#
" Signatait a of Licensee/Permittee Date #
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8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone '1
ISEC,TIiDN"10'111COR1fERS'CQMPENSATlON INSURANCE Al•FIDA1fIT(M Lc '152,§25C(6))
�, v,
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....... 2--- 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 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
r
Up
s °
Mio
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing l
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑. Sheet❑
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
DIM
I, �✓(/- as Owner of the subject property
hereby authorize L` to act on
my behalf, in all matters relaVve to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that the statements anX 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 Owner/Agent F 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 Parkin 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:
JW
y
City of Northampton
r 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
r '
$ECTl1�IV 1 JTE,INFORMATION' ,
1.1 Property Address:
� «�,r. �e,�� � � ��C���,�,��`�rJ�� � ��dit�{JI���� � ���IrXI�•�y'af14 -
SEC fflN 2 pROAE13TY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
f�'✓ C� Telephone
Signature
- 2.2 Authorized Agent: �}-
,,v '�► V I' �� - �� �2✓Y2 d �r�►Y1�13L y�Y�.
Name(Print) Current Mailing Address:
Signature ly Telephone
CT 'IIMA`IIIwi1 04ST 120, -16-4 0�0�5�t`S .
Item Estimated Cost(Dollars)to be Ofto�el Use Only
completed b ermit applicant � a.., . .� , .. �,3,• �,,,_ "3 � '
R 3
1. Building 5a} B�rPlrgP,errtt 'e� �
2. Electrical (f3)I~Stimatd 5Z6 ta( asoft ,
.Coristnic�ion frtirri''6
3. Plumbing ?BuildmgPerr►i�t Fee ,�r
4. Mechanical (HVAC)
I
5. Fire Protection
6 Total (1 +2+ 3+4+ 5) Chec}
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Bail �a C missaonerllnspOctbr of ciild>ngs „
o Date
101 STRAW AVE BP-2006-0374
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-022 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0374
Project# JS-2006-0545
Est. Cost:$5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq. ft.): 9583.20 Owner: BAK HELEN C&
Zoning:URB Applicant: Larry Paquette
AT. 101 STRAW AVE
Applicant Address: Phone: Insurance:
40 East Green Street (413)527-6375 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:101612005 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:
FeeType: Date Paid: Amount:
Building 10/6/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo