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29-310 O O Crrl3 crfl�>?� tl��ttlt}�t�lt �tcs.nrhncctta —_ DEPARTMENT OP BUILDING INSPPCT1o1'S = 212 Alain Strcct ' Municipal Building Northampton, Afass. 01060 «rORICE WS CO)ITENSATION MSUTZA-NCE AFFTD M' (liccuscc/permittcc) _ - -- v,rith a principal place of business/residence at- - ---- (phone =) ty/staic(zi p) - do hereby certify, under the Pa.inS and penalties of pegury, that ( ) I am an employer providing the followint_ worker's cotnncns:: ion cove-age for illy C-luployces wotiallg Un tills job. (Inn> �c Corer n�) (P0hC-; Nu_-n xr) or Datc) ( ) I am a sole proprietor, general contractor or homeowner (circle one) aid have hired the coatractors listed 'below who hive the foUo%ving Worker's C,0D enSa1]on pCkles: (Name o;Cony mc,o-) ([nR ran, Cornpan)yi'chcr �'umLY:) D->:pi;!uoa Date) -- (Name of Coorraccor) -- (tnstrancc ComanyvPok—y (Exo r,Lion Date) (Name of Contractor) (InsZt.rancc Compan)•/PoL-C)• Nusbu) (Ex piraon Date) (NaM-C of Contractor) Rasur-anoz Comrany/Pohcy Numbs) (L-xpirano Date) (mach :�eal c'xd ilncr-:a� to xruLL inforv-i,_'ioo twtainin�to.11 ooa'r.�-o�) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner perfomimo to all the work myself. NOTE:pk--s Ix cave tt,•• 'cnJC bcG–O"n_- Hbo CMPlay pesonl W do e ,=-+ Mpav%�Urx oo.d..ell_Z of aoi nxxt tbrn t17 -trill in u',1 C+i Ux t onm ,-Der rc do of oa Lb, p-ouDrt�zppurt,(:m tbcr �o-x tt -ily ooz::d-czi Lo b ctployc� n c the..�i c Imoa Act(GI-152--is 1(5)�mfVtirat)oo try e bomeoaw fn:--b __�ex permit rL y e i&moe tLe IcpaJ rtaau of an czVloyx uric,-r dw Wo i olc COCap l Q n-&- 1 undcrtixnd die x copy of tbi'ar- ,m m..y bo f---,ind to tbo pcpnrtmen,of liid.irri el Anodeat�'Offioo of U�for Um oav`z'sc VcriL=1100 and tttl L•J nt w realm eovcr ,under sccUca 25A of MOL t S2 exn Iczd to the i�03 of a retail P-11-of s 1510,of up to S 1-500.00.r,(Vcx bmpri�of uP to Doc yta cad CiNil Pmht o in tx form of n Stop Work Order-A. fire of 5100.00.dxy tgz a; m- Fa dcp.— Z�� u.c Drily Pcruvt Number _ P:- Sipnaturc of LicClls m cclYcrittcc c� ti 4 -' E �li�anrhncclta DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Bmldmn Northampton, Afass. 01060 WOR1Q?R'S CO\/Q'ENSA'nON [NSURA-NCE AF MAVIT ,� Ste/✓ �' /1�Y /r - (li ccuscc/perrnl ttc�) v,11th a principal plat,- of busineesslresiddeerice at. �113 _5 - 148 do Irereby certify, under the pains and penalties of perjury, .hat ( ) I an an employer providing the following woi-kcr's coin, cns:a�on covc.��c for Intl etuplovccs wormy, on utis job (tn=_-mac: Corer nv) (Polio; NU_-ar/_-r) --_._ �✓:pir uon Dare) ( ) I am a sole proprietor, general contractor or homeowner (c c',e one) and have hired the contractors hste-d below who have the iollornD 9 worker's com-3ens2Don pe!!cies: (Name o"Co:).aMao-) (Insilmnc;, CoinpsnyiPclic, NumMr) (Name of COniraclor) OjL1 L"aI]C:: Comoaav/Pot -v NtlpCsi) (xpiM.ijon Date) (Name of Contractor) Cmsuranc: ComTiioy Polio)• Number) (ENpiraon Date) (Name of Contractor) (Iosumzc—_ ComraoyfPolicy Numb,�s) (E\p dhoti DaLc) (a a i oczl cJ d Inc ci n to ux u6 uaforn..a oa rw n nb to all oo rr co ) ( ) I am a sole propnetor and have no one wor4ang for me- ( ) l am a hone owner performing all the w lf. work myse NOTE:plc tx uc t Jc bcaroµvcn +bo caVIO-y p,,_w 6D �z� -c�C c�av•or oo.d..c11V�of oot mom ain Lnr.Lnf in the bomoo acr r,=id�or oo the pD,n zppu ten L'tbcco coloycs Art(GL157_�1(5)),npgric 6oro try>6anr�a�a r c v o psm n y cvd�o L I<pl 0—t,-of cn loyx uodrr din Wort;o1,C'.omrxo3i Ad 1 ands —d d-_�a copy of tbi,cxircmcat o y bo f---,id d to tbo Off—of rn,uiow for trm eovezSe vcrifretioa-v� Uu f_ikz-c to tca=eovm%,c under So�oa 25 A of MOM 152 c,lend w the i-.1?0!�> Oa of cr min�l poalwcs ., 000iist>;tg oft CID<Of Up to 5 1_SO0.00 ar,-VCX iln� of up to one yc:r tnd Civil pcoihic in d�fog of n Stop Wort order and a Ciro of s 10o.00 i my tpdwa mr For dcp..tn>;=-il u�c onl7 Lot '�/J�y-?�//J�' ` •. Pcruv( NtLfl]tX;r Signalu f Liccncr�'crnuucc ����� - __ CTI C�3N5TRUCTION 51"I�YIG a .,.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone S;ECfIQN »W{} l I 'CQmPtN �TIQ1�11N5r_RANCE A FIDAYIT(MA L.c.11 2,§2'5C(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. ned 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 1*08.3.5.1. 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. Th undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of N rthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. omeowner Signature ` 4,ry r' New House ., se ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative o Renovating unfinished basement Yes No Plans Attached Roll 0 -Sheet❑ AM 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 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 ECT"11 rN WN AU HQl I Afi ON fiQ lit Cl �Pl:l l lED WHEN C?WNi: S dl+lT Q C©N� CTQR API�I.IS I"Olt B ,��.D.IIGi PEI;;MIT as Owner of the subject property hereby authorize to act on my b ehalf, in all matters relative to work authorized by this building permit application. v/ /'4,4--in Signature of Owner Date l as Owner/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. 'gned under the pains and penalties of perjury. Print Name ignature of Own 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 6� )S ilding Department 212 Main Street n Room 100 JUN 6 Ithampton, MA 01060 phone 13 587-1240 Fax 413-587.1272 >. �..- tr:Tir�S APPLICATION TO COWSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE'NFORMATti N 1.1 Property Address: PRO y y' r SETiO#il 2-PROPERTY QWiERiHIP/AUTHORIZED iA GENT 2.1 Owner of Record: SP/'T me(Print) Curr t ai Addre s: Telephone Signature R� 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone FTION S ES FIVfTEQNSTRIICTIONT_ ' . Item Estimated Cost(Dollars)to be Official,Use Only completed by ermit applicant 1. Building (a)!Btflidirtg Perrnitfee 2. Electrical (b);Estim ated Total 064t of Construction,from.;S,. 3. Plumbing RuRdin Rermitfee., 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 + 3 +4+ 5 ;Nvhiber Th a,Uttl tt flu :pffl+WiaN!.Use nM Sri lirigP rrr�it Number: Gate Issued . ightute , Bld�d �Cmmtsstner}lr► ortll�ditgspa#e 358 ACREBROOK DR BP-2000-1097 GIs#: COMMONWEALTH OF MASSACHUSETTS ap:Block:29-310 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2000-1097 Project# JS-2000-1961 Est. Cost:$1000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor. License: Use Group: Lot Size(sg. ft.): 11717.64 Owner. RIVERA SHIRLEY Zoning:URA Applicant: RIVERA SHIRLEY AT.• 358 ACREBROOK DR Applicant Address: Phone: Insurance: 358 ACREBROOK DR FLORENCEMA01062 ISSUED ON.616100 0.00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER EXISTING 1 LAYER POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Qnderground: 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 6/6/00 0:00:00 2032 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo