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Fe J S' 6 ' r 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