32C-154 (3) I
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
��e 1 1
(If ce nserJpermi ttee)
with a principal place of business/residence at:
o QI � (phone#) 11
city/state/ap)
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:
ansuxance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor r homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
hi co /4o-7/1q-z 7Id-V-6c -_
(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)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atfach adMoml shoot ifnec-c ss to include infornaxtioa pxtaining to all ooat acorn)
( ) 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 aw2rc that whilo homcowo=who employ persam to do m.,rn. conntR dion or repair worse on a dwelling of
not more than three units in which the hon»owncr resides or on the grounds appurtenant 1Jxercto arc cot generally oonsidacd to be
employ=under the workcta.compc=aticn Act(GL152,=1(5)),application by a homeowna for a 11ccase oc permit may evidmce the
legal status of an employer under thn Worlccls Companaiion Act
I undcrsund that a copy of this ctaicmcnt may bo forwarded to the DW.tO c of Indruf d Aocidm&OfSoa of Insurance for thn
coverage verification and that failure to secure coveraga under section 25A of MGL 152 can lead to tho impos—of criminal pcnal -
consisting of a fine of up to 51,500.40 andfoe impruonnzcrst of up to om year and av2 pemlt c%in the form of a Stop Work Or+da and a
fie of 5100.00 a day agaiwl ma
For degatm-t"tike oily
permit Number
_ Lot#
x.
Signahrre Li -------
ern it#ee e :::
SECTIO14°.8 :CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor, Not Applicable �❑
-!
Name of License Holder: t 1.— - a�I
License Number
�.k 11
Address Expiratioh Date
76
S nature Telephone
ien NOt Applicable ❑9 . tContac
Company Name Registration Number
Address �M 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 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
SECTION 5- DESCRIPTION°-OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:54 (V 900: PePc 'c oo\� I'T p S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6aElf New hou"se andtor-'addition to eicis'tirig hou"sing;:°completeahel,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
SECTION7a OWNER AUTHORIZATION TO BE COMPLETI`D WHEN
0111�N�RS AGENT OR CONTRACTOR APPLIES,FOR BUILDIN`NG;PERMIT
9
as Owner of the subject property
1 R
hereby authorize e f M ii _6 A to act on
my behalf, in all matters relative t6 work authorized by this building permit application.
Signature of Owner Date
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.
Signed under the pains and penalties of perjury.
Print NaWofwner/Ant
.7 1 L,-2,
Signatu 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 ci 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:
t�'1
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ffnrpTnF f Northampton Ile
Ing Department Main Street2 5 2001 Room 100 Wa erlWe l N rtha pton, MA 01060 587 1240 Fax 413 587 1272 ;Plot Siff P BUILO GIN CTIO Other Speoi
NORTHAMPTON,MA 01060 ...._ . p., ... � s _. _ erg,�_-_, .,� ..
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 7
This section to beicompletetl by office
1.1 Property Address: gig { `
a Low,
Zone Overlay D str ct
Elm`St. District-. � : CB Dstric#�
---�:-�-�------
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
.1 Owner f Record.
1' a o6d
Na nnt) � Current Mailing A dY�s:�,�r
bon�: a f) L +� Telephone CLOG
Signature _
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
/ 0-76
Sig ature Telephone
SECTION`3 - ES'TIMAT,ED CONSTRu'bN COSTS
Item Estimated Cost(Dollars)to be official UselOnly
completed by ermit applicant
1. Building �o (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) Check Number
This Section For Official Use,Only
Building:PermitNumber: Date Issued:
Signature
Bui,l„dig.Cornm1ssionerAnsPector of Buildings,.,. ., Dof
r
g'I1TUSI, 4'� -, BP-2002-0088
GIs#: COMMONWEALTH OF MASSACHUSETTS
h ;32C. 154 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofmQ BUILDING PERMIT
Permit# BP-2002-0088
Project# JS-2002-0128
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEITH HAMILTON 074129
Lot Size(sa. 8.): 1001 8.80 Owner: TOUCHETTE ALBERT F&JOYCE M
Zoning.URC Applicant. KEITH HAMILTON
AT. 18 KINGSLEY AVE
Applicant Address: Phone: Insurance:
27 CAHILLANE TERR (413) 587-0763
FLORENCEMA01062 ISSUED ON.71241010:00:00
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. 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 si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 7/24/010:00:00 285 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo