Loading...
32C-123 (6) B�0 4e (rxt�l Jaf &NO t1julllptoll aBrsanrhnsrtta m DEPARTMENT OF BUILDrNG INSPE'CT'IONS 212 Main Street ' Municipal Building - Northampton, Mass. 01060 W0RYCER'S COM ENSA'ITION INSUR.-A-NCE ATTAMAVYr (li�ns�c/pernv ttec) with a principal place of busuless/residence at. _ AJ (str�:1J c i ty/naie/zi p) do hereby certify, under the pains and penalties of perjury, O I am an employer providing the followim, wor} er s cotnpensat,101-1 coverage for my employees worldrlg on this job-. aas-usance Company) (Policy Nuzihx-r) (Expiration Daze) ( ) I arri a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers coi- pensa�OFI policies: (Name of Contractor) (Insurance Company/Poticy Nu-rnl--r) (Expiration Date) (Name of Contractor) (Laauancc Como anv/PoIicy Number) (Expiration Date) (Name of Contractor) (Expiration Date) -- (Name of Contractor) (Insurance,Cornl ny/Policy (H-xpi-ation Da(c) (anacdt A&Jit Cc JA z xct ifncccnATN to ixludc iafoanition pertain tr,all l O mii a sole proprietor and have no one for Cie. I am a home owner performing all the wort, myself. NOTE:ptesae be aware ttut tNb lc -,--play pc-,—Om to di c a tray c ar:- r c Gr repa Lr WWk on s dN,cIling of riot m ce than three units in wt-ndt the honboancr reside ct oa Qu E oputte: rl lhado -r rxt C,:� ilIy oxiducd to be c^tployca under the tvarku s oaz tticn Act(GL152 i(S)�,arpl:A ice bye hcTnzouzrs for a{;c rc x p r n t nuY cv daxx the legit aR us of an employer under the Workres Compcnlslion A.,d_ I understand tlut a copy of this etat.cmcut m.y be famamtod to the Dctxiitnrar2 of lc>di t iel A"vi—�Y Ofriao of LII iDCe for tlm covaa�vetiFication and that failure to actirrr coveragO undx scelion 25A of htQl,152 can lr.d to the intpositiort of czicim-tl penalties a fux of up to S 1.500.60 arwor unprisoaax of up to cqc}car and Civil prnnitin in dx f-M of a stop Work Ord-and a fen 5 GO a ds siu uY Foe deps tnwC'1 u,o arly j2 �� Permit Numtxs rp;t _Lot# j Sipklture of Liom er iucc _�,,{]yy.Y-Ft ESQ d �c,l:�:__.,. "'—._ .. I SECTION 8-,CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ` C "�-'�- Z - `� "k � 7 C - 5— 7c, License Number U Addres / Expiration Date Signature Telephone r9 Re istered,Htimelim r. vemen _ N ot Applicable El 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....... 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 buildiny. 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 fer 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 yo in this permit. The undersigned "homeow s and a�StTrrtesr� }antlsib�i y for compliance with the State Building Code,City of Northampton Ordinances, at oc _onino a� 'ta " .Massachusetts General Laws Annotated. r Homeowner Signatur SECTION 5-!.DESCRIPTION QF PROPOSED WORK(check;Ol aaalicaWe) New House ❑ Addition ❑ Replacement Windows [Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: LJ E)c'os'y Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 6a 'IfrIN ho"use.and:0 .ad iition-to-"6XWhz' ou"sing,h:complete.the g followin : a. Use of building : One Family-c 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 _ as Owner of the subject property hereby authorize _ _ to ac; or my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date `C ff �Z- �' _ as Owner/Authorized Agent hereby declare that the statements and information on thi foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. � — Z)() —/--z — Print N m nature of Owner/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 I 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 frorn 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 Sf F? F Building,Department Curb>Cut/D=, e 212 Main Street SeweSep_�c I. Room 100 Wa erlWeti r Northampton, MA 01060 TwoSetso Str c an ph'oSe 413" -58'7-1240 Fax 413-587-1272 PI t/SitePlaris� Other Specify 7 -_ �. _ .. . : s.�._ APPLICATION TO CONSTRUCT,'ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be-completed by office Z j t��-(�( ! Map Lot Unit \1�l`t Zone_ Overlay.District (J Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �^ Name(Pr� Current Mali ng Address - — — � 7 Z � �---- -- _ _ Telephone Si ature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) __Aimated 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 This Section For Official Use Only Building Permit Number: Date Issued: Signature: _— I Building Commissioner/Inspector of Buildings Date 28 FRUIT ST BP-2003-0565 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 123 CITY OF NORTHAMPTON Lot: -001 Permit: Building Cate orv: BUILDING PERMIT Permit# BP-2003-0565 Project# JS-2003-0928 Est.Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq. ft.): 5401.44 Owner: DOHERTY MICHAEL J& Zonin :Ug RC_ Applicant: DOHERTY MICHAEL J & AT. 28 FRUIT ST APPUcant Address: Phone: Insurance: 28 FRUIT ST NORTHAMPTONMA01060 ISSUED ON:12110102 0:00:00 TO PERFORM THE FOLLOWING WORK:I N STALL WOO DSTOVE 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:Oik' /-3 e-T I V THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 12/10/02 0:00:00 1318 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo