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The Commonwealth of Massachusetts
Department of Industrial Accidents
600 Washington Street
Boston,Massa 02111
Workers,Cow ensation Insurance Affidavit:Buildinp?iumbinr/Electric•.i.ContractQ s
name: �•����� .9h/s��-, .
address 13 7 —14 4V
city '410 Ole 4 a phone# 5 7 a O
work site location(fbll address):
❑ I am a homeowner performing all work myself Project Type: ❑New Construction EIRemodel
OMIam I am a sole o etor and have no one workin in an ca aci ❑Buil Addition
an employer providing workers'compensation for my employees working on this job.
company name: �� h�C •n �'� Sc / v i G: S
address'. 132 "'-7
city, /Pf0 ^�!/��—''" '0� _ Rhone#: 5,5'y 7?o 0
nsurance co. �C�1Y /T/!,5!!/�.r C o'iry# 7 O.3
I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed beloy✓who
have the following workers'compensation polices:
company name:
address:
city Rhone N:
insurance co.
comlpanv name:
address:
A
city: phone#•
insurance co. lirr#
u. r//lG ,r :%6✓r.a/ i,,,,,,, j,.,.,,uv rli�/./w 7; ,.nw
F.d to secure coverage as required under Section 25A of MGL 152 cen kid to the imposition of criminal penaltim of a fine up to$1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a flee of si moo a day against me. I anderstaw that a
copy of this statement may be forwarded to the Office or ivvestiptions of the DIA for coverage veritlratio[L
I do hereby eertlfy under the pains and penalties ofperjury that the injorination provided above is true and correct
Siganature" G�� ��""— Date __
1.20 Za'5
Print name /C er zv,�rr, Phone#
4
official use only do not write in this area to be completed by city or town official
city or town pcnnitliiccmc i ❑Building Department
Board
❑cbeck U immediate response b required ❑Ltccnstng
❑Selectmen's Office
fsestth Department
Contact person: phone#,
(om+.d SepL 2DO)
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: D7 3 y 5 y
` License Number
Address Expiration Date
44 -69t - 72o6
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
/3 2/7 Z
Com an 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...... ❑
11. -'Home Owner Exemption
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 buildine 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 E] >6
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[❑]
Brief Description of Proposed oo X'-
Work: K�/J�Ce e'X.-S 7
Alteration of existing bedroom Yes X No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rol -She
6a.If New house and or addition to existing housing, complete the 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 Qf heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck 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
I, �� . / pti e / as(tlwner of the sub'
property s
hereby authorize "e, /s
to act on my behalf, in all matters relative to work a�utthhooririzzed y this building permit application.
Sign re of Owner Date
as Owner/ orize
best of my
e by declare that the statements and information on the foregoing application are true and accurate,to the nowledge
and belief.
Signed under the pains and penalties of perjury.
of / C�t•t,-,( -!5, /, 7of�
Print Name
"e
;F5—
Signature of Owner/Agent Date
• s s
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:�S R: �S L: R:
Rear 3Z: 32' L�
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 Q DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
.212 Main Street Sewer/Septic Availability
' fzoom 100 Water/Well Availability
Northa' pton, MA 01060 Two Sets of Structural Plans
phone 41,;3-5871240 Fax 413-587-1272 Plot/Site Plans
JJJ Other Specify
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
Map Lot Unit
/ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ////--
Name(Print) /� / Current Mailing Address:
�lc-�C —+^y�JS�+�-z¢ q//4C k Telephone O J
Signature
2.2 Authorized Agent:
'414� /
`,5�/i..�� �J/"/7 ✓mac.-a-1.n I�aY /VD�'TI'.i.'^"t�
Name(Print) Current Mailing Address: JF
1-174z l41 594/-7�ao
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)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number Q
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1007
APPLICANT/CONTACT PERSON INHOME HANDYMAN SERVICES
ADDRESS/PHONE 137A DAMON RD NORTHAMPTON (413) 584-7700
PROPERTY LOCATION 15 AUSTIN CIR
MAP 29 PARCEL 371 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 725 4
Typeof Construction: REPLACE EXISTING 10 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 073454
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
v� /0-00"s
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
15 AUSTIN CIR BP-2005-1007
GIs#: COMMONWEALTH OF MASSACHUSETTS
VVp Block:29 9371 CITY OF NORTHAMPTON
Lot: -001
Permit: BUiidinQ
Category: BUILDING PERMIT
Permit# BP-2005-1007
Project# IS-2005-1388
Est.Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: INHOME HANDYMAN SERVICES 073454
Lot Size(sq.ft.): 11020.68 Owner: HOOVER CLIFFORD A&GAIL E
Zoning:URA Applicant: INHOME HANDYMAN SERVICES
AT. 15 AUSTIN CIR
Applicant Address: Phone: Insurance:
137A DAMON RD (413) 584-7700 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:4126105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING 10 X 12 DECK
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:
FeeType• Date Paid: Amount:
Building 4/26/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo