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17D-027 (6) j � r 4-�HAMPTO Boo of 'Wart1pill}ltc 9 6 Aiasanchnsetta' — m DEPARTMENT OF BUILDWG INSPECTIONS 212 Main Street * Municipal Building Northampton, Mass. 01060 y 'J WORKER'S COMTENSATION INSURA-NCE 'MAVIT - - (licenset'/permittec) with a principal place of business/residence at: 3 4 ��gk�1DCSRn �� -1�rtS�n f-77ki 0.3q,5t ()honer#) foQ3"336 ` �'�25� (strret/ci ty/statrizi 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 worlang on this job: (Inszumnce Compauy) (Policy Number) (Expiration Date) 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) +r. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Pol cy Numbei) (Expira6oa Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (aaach addibooil shed tfnccczvry to include mfonnsttoa ptstauxing to all ooatme rs) Z am a sole proprietor and have no one working for me. ( ) 1 am a home owner performing all the work myself. NOTE:please be aware that veElo homeowner who employ pcnoll,to do nmhajcnancer w-,zt-, roc or repair vrork on a dwelling of not mote than thtno units is which the hotnoowner rides«oa the g noun appurtcnanl iha'tD arc not gaxmlly oowidatd to be employers tinder the---k i ooalpcnzatioa Ad(GL152,ss 1(5)�application by a homcowwr for a Gccase a permd may evidence the regal vtatuc of an employer undertho Workcez Compemation Act- I undenUad that a copy of this ctateasom may ba forwanlnd to tho Dtpcutmcat of tndautrial Aon aify OfSoo of ans+u—for the coverage vc ificatioa and that failure to aoatre covetago Under socdoa 25A of MGL 152 can lead to tha imposition of criminal pcmltiea oomistu of a fine of up to S1,500.00 and/or imprison of tip to ow year and Civil peaaltics in the form of a Stop Wort;order and a firm of S 100.00 a day agaimt me For dcp:rtNuml use only permit Number iviap l Lot Signa f LicenseelPermittee �e SECTION'i8, .CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder :�� h t 5 _ n-?Z��k License Number a,�g t3--eP+11b&*o )?d XT Cry Address (93,45 ( Expiration Date tainscbk-' PI W , 6 03 334, ?72S 5 Ih lugee-Oq t rtnc Signature Telephone j 11ci/e rtic,� �-�'- n►Q�� ©tu? 00 T� � u r9Regi" red Hometlmprovfement Contractor 'y_a„ ,, _„ Not Applicable ❑ Q2iCV bj 's Company N e Registration Number 32q V"4- -J" 1�) S l y (o Y Address Expiration ante Telephone 60Y--,33L ��2 3 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 permit. Signed Affidavit Attached Yes....... No...... ❑ 1. ;omexOwnerEem:ption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie 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(: 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 d�= SECTIONS DESCRIPTION OF PROPOSEDWORK(check alf'-apalicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work:. -VR%p KgA Ae"k\" (,4d :rns M 35 'j P_ ASp6L4 Antes Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet ❑ 6'a Vlf`New house and"or.zadtlition to existing tiousinfx comp16t6Ah-6 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? In. 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 S,ECTION`,7a-bWNER�AUTHORIZATION OBE COMPLETED WHEN OINNERS:AGENIT OR;CQNTRACTOR,AP L S FOR BUILDING PERMIT 4 t "1�-J to-?at Owner of the subject proper -- hereby authorize Am— I `> I4(- to ac', my behalf, in all matters relative to w r authorized by this building permit application. Signature of Owner Date 66-ey ^`' 1",c�k as Owner/Authorized Agent hereby declar-eftth-att 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. �aeac � trs 1c Print Name Signature of /Agent Dat f t r � 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 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: r City of Northampton Statush ofjPerrnit� �fla Building Department Curb Cut/Dr�wa p 212 Main Street SewerlSe�ptic=A�a►�llt�y Room 100 1a�terl�WEll�vallability rthampton MA 01060 Two Sets ofStr c#ural�Ffans � 14 LWD i 587 1240 Fax 413-587-1272 Piot/Site Plans � e� _ Other Specify �,.. .-,.. .i . ..a�.. DEF1 DWEI , � 6�CON TRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be'completed by office' 1.1 Property Address: Map Lot'.. Unit Zone Overlay District " 1 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: c ( (9 (e <w�/j Telephone q l 11>Signatur --- 2 2 Authorized Agent: t ' l� CIA Q �1- ei 5 K 39 4 I�cAA1 b� to(r)S)I-Ae Name(Print) � Current Mailing Address: Signature Telephone SECTION'3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only coin leted by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of '?990 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 . � BP-2003-0149 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2003.0149 Project# JS-2003-0284 Est. Cost: $7990.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HARRY FISK 072486 Lot Size(sg. ft.): 16335.00 Owner: Milton Hanzel Zoning_URB Applicant: HARRY F I S K AT: 71 STRAW AVE Applicant Address: Phone: Insurance: 324 BRATTLEBORO RD (603) 336-7725 H I N S D A L E N H 034 51 ISSUED ON.8112102 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP, PLY & 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 Sisnature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/12/02 0:00:00 2729 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo