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C�wrcc, DEPARTMENT OF BUILDING G INSPECTIONS • wiig 1
. 212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COM?ENSA'I'ION INSURANCE AFFIDAVIT ---\.
1 ,
, _ C ' G : -)
(Iiccnseddpermittec)
with a principal place of business/residence at
— — — (phone # #)
(street/ci ty /statelz p)
do hereby certify, under the pains and penalties of perjury, that.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insu_rance Company) ( Policy Number) (Expiration Date)
4.,,,
,,
am a sole proprietor, general contractor or homeowner (circle one) and have hired
theontractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Cornpany/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(attach additional sboct ifneccisuy to ioc}uc informatioo pertaining to all o= ctradnrs)
(14 1 am a sole proprietor and have no one working for me.
( ) 1 am a home owner performing all the work myself.
NOTE: *Z « be aware that while bomcawncra who autp lay prso:.s to der m_aurtcaantc, col rueioa cat repair wort: on a dwelling of
not mccc than thr o units in which the bo;: oowhar raider or oa teat grounds appurtenant thereto arc not gcnorzlly considered to be
cmployaa urv the avoticu's oarapcasaticn Act (GLI52, s 1(5)), appliction by a homeowner fora ticcnx a permit may evidcnoe the
legal static of an employer under the Woriox't Compensation Acc.
I understand that a copy of this ctat.cmmt may bo forwarded to tbo Dcportmcot of Industrial Accidrnt? Offioo of Insuranoo for the
coverage verification and that failure to ✓sure coverage trod-r section 25A of MOIL 152 can lead to the imposition of aimin +l penalties
caiiisting of a fine of up to $1,300.00 andlor imprisoamcut of up to one year and civil penalties in the form of a Stop W oric Or&r and a
fine of 5100.00 a day cgniast roc.
For dcpntnrrdal u.so only
Permit
Number
`ti -/.-,` �� .•,,, i 1' �• �' �• o Lo #
m $tgnat xre o' iccnsee/Permitttee . 1 — 1 : e •
i.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Nuifiber
�dres �� Expiration
Sig atone < Telephone
�,e _ r "p�- i ` t .�"F . r c� �r� �'4a +r •�t � x
9: Imprgiiement Contractor ,,, �z�, ,„ „_ ^,,,, lei , 1. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 4Y No ❑
,om t ner = empti a n
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 fe- which this permit is issued.
Also be advised that with re C„rence to Chapter 152 (Workers' Compensation) and Chapter 153 (Lia }:ility 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 _ __
SECTION'5= DESCRIPTION:OF PROPOSED WORK check all- a..licable
New House ❑ Addition Cl Replacement Windows Alteration(s) ❑ Roofing 11)`
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: y .�1 w r).X. A k4* S t v" _S 1 \ 1 r 1
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement _ Yes No
Plans Attached Roll ❑ - Sheet ❑
6a:-IfINew house andvor.'addition to existing' housing ;completeithe ;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?
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
1, -\‘ „\\ 'S '
\ ( r . N � k, ; , 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.
t3 of'
Signature of Owter Date
•
(1 - , as Qwu4f /Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Siel under the pains and penalties of perjury.
C
(•(
?rnt N�me
)_
r g- nature of 6 ner /Agent O 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 yo
(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 v 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 I/
IF YES, describe size, type and location:_
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IFrYES, describe size, type and location:
.6
City of Northampton S t s� i 1il
Building Department C t fa C u t' 1 s
212 Main Street Se er /S i 1
� `�
Room 100
vv er ' ® - �, �`
�" °
Northam MA 01060 7 aSetsna ��
phone 413-587- 0 Fax 413-587- 1272 RlatlSiepl M�
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Qt �ier #Sped r #, s
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This,sectionto be completed by office -
C". -.i \\( ti1�c� c Map lay Lot Unit
� m �� , � Zone Over Distr ct
Elm St. District CB District
SECTION 2 - PROP O /AUTHORIZED AGENT
2 .1 0. n er of Record:
Name (Print) ► C mg Address:
' /2. <' , ..6' ey.�� - G G� 1.`-1-
Telephone
Signature
2.2 Authorized Agent:
s
Ita -Poe (Print) Current li ng Address:
l Mai
.._ � Y t t r�c..\
Signature I Telephone
SECTION 3 ESTIMATED CONSTRUCTION. COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical E.timt
Construction ated Total Cos from (6)
of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) 'C tz Check Number
. This ection on For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Co mmissioner /Inspector of Buildings Date
•
BP- 2003 -0540
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2003 -0540
Project # JS- 2003.0893
Est. Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CDT CONSTRUCTION 130152
Lot Size(sq. ft.): 6011.28 Owner: BOROWSKI PHYLLIS B & J DIDER &
Zoning: URC Applicant: CDT CONSTRUCTION
AT: 8 HANCOCK ST
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585 -8677 Workers
Compensation
FLORENCEMA01062 ISSUED ON :12/4/02 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/4/02 0:00:00 4948 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo