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17D-060 (6) . i !`" :,° `` .1 ., i } r t: ti I 1 ,i .�.,; i �I �i ;' l '� I i i ••R �� __._._.__......._._.. _� ,._. 1 3 r7 1 T,oL Rzziv< - Ab- El NEw t Crff� of 'Wart4ttntpfor Ix a � �tiffitllttftttf DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT L (Iicensee/permittee) with a principal place of business/residence at: (phone#) ' (street city/state/zsp) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my ^I 4� 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poky Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach addr6ocal sheet if nocerwy to include intormytion pertaining to all ooarvd=) 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 aware that whilo homeowners who employ persons to do mai*�*____M+nce o=dn Lion or hair work on a dNeUiag of not more than throe units in which the homeowner resides or oa the grounds appurtenant thereto are not generally oo=dcnd to be employraa under the vmrkeez compc ou4ca Act(01,152,ss 1(5)),application by a homeowner for a Gocise or permit may evidenoe the legal rtstm of an employer under the Woticeds Compensation Act_ I understand that a copy of this ruternaA may be forty w ded to tho Dopwtmcnt of Indu*ial Aooidaa&Offioe of lanww'00 for the coverage vertfia600 and that fadUrc to sea=ebverago under se cUoa 25A of MGL 152 can lead to the impo oa of criminal Penalties 00,misting of a fine of up to S 1,500.00 and/or imprboamead of up to one year and civil pensi ies in the form of a Stop Work.order and a f=of 3100.00 a day ageing tne. For dCP=tmer W use only Permit Number Map# Lot# —r= n,of Licensee/Permittee SECTION 8-CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone EMISSION NO .. k 2... ... r g Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 141-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. igned 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 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 unde is permit. The undersigned"homeowner"cert' ies d assu es responsibility for compliance with the State Building Code,City of Northampton Ordinances, State a d cal L sand State of Massachusetts General Laws Annotated. Homeowner Signature F. -giQ P I I'c e rN ew House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ] Brief Description of Proposed Work: /"No i�� ��7 z, r Alteration of existing bedroom Yes Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ :rr � 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 SECT QN 7a-OWNER AUTHORIZATION -TO.BE COMPLETED WHEN _OWNERS AGENT OR CONTRACTOR APPLIBS FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on my beh n all titters relative to cork authorized by this building permit application. a ure o n r Date 214 Z1_dZ .t?.�© ✓(/�'lf/ s Own rr Authorized Agent hereby declare that the statements and information on the foregoing application are true and acc , o the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name + A. Signature of Ow r/Agent Dat I �' � ,- I'I i i '� I i i �I ', ,�. "' 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 9 Frontage ,�7 Setbacks Front f �/, '-"0 Side L:07,dYR: L: R: d Rear Building Height Bldg. Square Footage 11 i' % Open Space Footage % (Lot area minus bldg&paved �Og if, parking) #of Parking Spaces / Fill: volume&Location A. Has a^Sp/ecial 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 _i DON'T KNOW YES IF YES: enter Book Page and/or D ument # 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. Vreere any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: i i 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 This s 00di,l come r# n 1.1 Property Address: s f Vo Unit 5 SECTION 2-.PROPERTY OWNERSHIP/AU'T'HORIZED AGENT 2.1 Owner of Record: ame(Pri ) Currqot Mailing Address: Telephone ign ure 2.2 Authorized Agent: , Name(Prin Current Mailing Address: Qll. O :;/lj Signature Telephone SEG'CItJN 3 r,STIMATEII CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official,Use Only completed by ermit applicant 1. Building - (a) Building Permit Fee 2. Electrical o (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) Check Number , Is Section For Of#icial Use Only Building Permit Number:'" Date Issued; Signature: Building C,orrimissioner/Inspector of Buildings Date File#BP-2001-0818 APPLICANT/CONTACT PERSON DRISCOLL EDWARD A JR&MARY F ADDRESS/PHONE 20 GARFIELD AVE (413)584-4333 Q PROPERTY LOCATION 20 GARFIELD AVE MAP 17D PARCEL 060 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL 27'ABOVE GROUND POOL W/DECK New Construction Non Structural interior renovations Addition to Existing AccessoKy Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE,kOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presentedibased on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Co Sion Permit from CB Architecture Committee O Signature of Building Official 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. , ' BP-2001-0818 cas# COMMONWEALTH OF MASSACHUSETTS titl CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: Above ground pool BUILDING PERMIT Permit# BP-2001-0818 Project# JS-2001-1531 Est.Cost: $5900.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sq.ft.): 28880.28 Owner: DRISCOLL EDWARD A JR&MARY F Zoning:URB Applicant. DRISCOLL EDWARD A JR & MARY F AT. 20 GARFIELD AVE Applicant Address: Phone: Insurance: 20 GARFIELD AVE (413) 584-43330 FLORENCEMA01062 ISSUED ON.•4119101 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 27' ABOVE GROUND POOL W/DECK 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 4/19/010:00:00 1197 $50.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo