17D-028 (2) a
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<n DEPARTMENT OF BUILDING INSPECTIONS —
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 y �,
WORKER'S COMPENSATION INSURANCE AFIIAVIT
(licens�rJpermittec)
with a principal place of businessJresidence at:
4 ►,. �o aJ rev" phone#} ��� ' 1167
(strczUcity/n f'/gip)
do hereby certify, under the pains and penalties of perjury, tliat:
(V�'l am an employer providing the following worker's compensation coverage for my
employees working on this job:
ji g«,ry &VI'VAI --4A)s63 Wcl'3;� -3ai' 77/--0)0 4 e), -jW
(Ins C-- Compan)') (Policy Number) (1api rat3'0n Daze)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have lured
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Znsuran Company/Polio; Number) (Expiration Dale)
(Name of Contractor) (Insurancr= Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (ExTLmtion Date)
(anarh additioail s cct ifineceu to include informsfioc pataiuing to nll condors)
( ) 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 awatc that whilo homcowncn who cmplay paiaru to do rnxjc��oxmtrucdon or repau work on a dwelling of
not mono than throe units is which the lbmoovn re=dcs or om the grour�appurtem thereto ate no(gco rady cowidcrcd to be
employcxa under the worka's oration Act(GL152,m 1(5)�application by a homeowner for a license or P=md may evidence tho
legal status of an employer under d--,o Works x Compomation Act
I understand that a oopy of this rtatcmcnt may be foewju d to rho Depart,,, t of Indau4ia!A=dmfs'Of5oo of Iivusnoo for rho
oovcrage vrrificatioc and that allure to ac=re eovertrgn under sccuoa 25 A of MOL 152 can Iced to the iu>pos On of criminal pcnaltica
000sisting of a fine of up to S 1,300.00 and/or iaxprisoumc=t of up to one year and evil peaaitia in the form of a Stop Work Order and a
fine of 5100.00 a day a&rinst tax.
For dg ft=1tnl use only
3't f Permit Number
y��o� Map# Lot#
Signature of Liccn-scc[permittcc Thte
ECTION 8-CONSTRUCTION SERVICES
T 1'
,.1 Licensed Construction Supervisor: Not Applicable ❑
I
Name of License Construction
601 A) L Cllr o
License Number
�2z 1,3R-1 -0 — c-)1- a ?-
Address Expiration Date
dO tC 4 70P) MA �� y���
Signature Y Telephone
Not t Applicable ❑
Company Name Registration Number
1Z Alol2 06 -'/2;- �o6 /
Addr ss Expiration Date
x, 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.
,,01nQigned Affidavit Attached Yes....... IV/ No...... ❑
4
..........7"A_�
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
#0W
TI C P h "' able
New House ❑ Addition ❑ Replacem nt Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ Other b-U-4
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?
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
;7—o x s1'%l as Owner of the subject property
hereby authorize z;z %N Z• 12 4? LD- 61k'�P_ S� xJ `� -1 C-' to act on
my behalf, in all matters relative to work authorizetJ by this building permit applicati .
Sig ure of Owner Date
L % ,�°�` as 9Authorized Agent
hereby declare that the statements and infbrmation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
OOLI-S under the pains and penalties of perjury.
Print-Name 7
�— • �-�-�- ' 3
Signature of ff/Agent 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 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 a Ya
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION 7
This section trsbe comple#ed:by office
1.1 Property Address:
--r�eA�.J ca C Map Lo w lJriit
Zone Qrlay Dlsrtrkt
t3 C 45
Elm St..District CB Djstrfct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: -
ame(Print)
� CuM Add
Telepho ne
Signatures/ T
2.2 Authorized Agent: y,
Name(Print) Current Mailing AddrY ss i
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ?� t7j (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) 7 S °� Check Number a-,7—
This Section For Official Use Only
Building Permit Number: bate Issued:
....Signature:
Building Commissioner/Inspector of Buildings Date
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63 STRAW AVE BP-2000=1059
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-028 CITY OF NORTHAMPTON
V
Lot:-001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2000-1059
Project# JS-2000-1900
Est.Cost: $8675.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq.ft.): 18033.84 Owner: MERSKI FRANCES A
Zoning.URB Applicant. B & R S i d i n q
AT. 63 STRAW AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01062 ISSUED ON:5124100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 T-
ype: Receipt No: Date Paid: Check No: Amount:
Building 5/24/00 0:00:00 17063 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo