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32C-240 (5) y 6 z,u „. � s { i r rh s NA; a rr t x t � t ©_ cv G 0 4 V, ,n '9 z. tl wry NwNrre a fl i C) ON L7 s r t ' 6y ay rvr � L Not Vol �� � •.� ,^*� ��� � � � ■ � � �rte, ,�„ �,�,,.=, � � ��,�-Y- '' rcg ¢ {S Mill � sw onammmmmmmmmww f' 5� �4fi 3 �ij � r ttAa''( � �e Crib of N ilaul tan r • T i � �B �ttsasrkttsrtis DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street r Municipal Building ' Northampton, Mass. 01000 WORKER'S CONTENSATTON INSURANCE AFFIDAVIT Nt��) with a principal place of business/residence at: (Stxeet/city/stale 2* 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: �y Q ( C.c�5: e� t�t"P1 ay `�`� W c.c TO,o 3:R (Insurance Company) (Policy Number) (Expiration Date) ( ) I am a sole proprietor, general contractor or homeowner(circle one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Numbcr) (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) (attach additional shod ifnecessvy to indwle information pertaining to sM 000iradots) ( ) I am a sole proprietor and have no one working for me. ( } I am a home owner performing all the work myself. NOTE.pltase be aware that whilo homcownua who employ paro=to do anintcnawr,consnxxion or repair work on a dwelling of not maw than throe units in which the homeowner redden or on the grounds appgtenwA thado ate not gtncany coc=d«cd to be employers under the worioees compeas4ca.Act(GL i52.ss l(5)�application by a homeowaar for a 6cca=or permit may cvidcace the legal ctatua of an employer under the workeet Compemation Act I understand that at oopy of this statement may be fo rwardad to the DopermsooQ of industrial Av i&u&Offroe of InomwwO for the covaige verification sad that failure to rocurt covmV undo smdon 25A of MGL 152 can lead to the impaaitioa of aimiaal ptxtaities ooasisting Of K Son VfVP to s1,c500.00 andlor*t600nxM ofup to one year and civa pem8ies in the form Of step work order and a fm of3100.00 nday agdad me. For dgs�asa�al use aotY Pt Mit Number i,,,tao Lot# 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder -- License Nu ber Address pp Expiration Date Signature Telephone Not Applicable Company Name Registration Number Address Expiration Dat Telephone 1'!©N 1#1- AitRift 'CtV Eli t # 1I1NSCFtDA1l1T"M.G. .,c 152,§.2s�iC{a4" 3 y r 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....... Id 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 New House ❑ Addition d Replacement Windows L Alteration(s) E Roofing ❑ / Or Doors ❑ Accessory Bldg. ❑ DemolitionQ New Signs [ J Decks [ J Siding[ ] Other [ ] Brief Description of Proposed Work: V C` Ax S"rcll?S kyN cs"'D `` �`'° Q"'�� Z)Qlf 1V%e- Alteration of existing bedroom Yes v1 No Adding new bedroom Yes No I Attached Narrative Renovating unfinished basement Yes 1No Plans Attached Roll 0• Sheet q/ s I 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? (VZ) d_ Proposed Square footage of new construction. Dimensions i e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each j I g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes V 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 J Private well City water Supply as Owner of the subject property hereby auth e ��*�'`4"' � S to act on my be , in al m r o workiuthorized by this building permit application. ure 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 Name Signature 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: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Sp cial 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. Ahere any proposed changes to or additions of signs intended for the property ?YES _ No IF YES, describe size, type and location: �t34 of Northampton r_ 'I Ing Department 2 Main Street Room 100 _ �QQ3 Ni�ra'fnpton, MA 01060 NOV 3 phone 413-587 1240 Fax 413-587-1272 APik'tlA'�4 ,ALTER, REPAIR, RENOVATE OR DEMOLISH MILY DWELLING $ECTftry 1 SITE tN�L1RNFATUN 1.1 Property Address:�r ff N SECTION 21-1 tTQ ER`tY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: V S-i can z S Na (Print) Current Mailing Address- Telephone T Si ature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone lok,cotts c of Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building a x 9 Permit Fee ;E 2. Electrical lta);� rrd Total Oost;cif Cant' coon from. 6 3. Plumbing Buildl�ilt ?ermi#fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 +4+ 5) ChC}i,t� '>Gber r ;a.t Thks'Secbon For ffi @U eta B tldlt Pet+rntt'f�ktrttber- Date I tuet{� Signature: oi4ioi6g Gomrnissioner/inspector of Buildings Date File#BP-2004-0538 APPLICANT/CONTACT PERSON Harlow Builders ADDRESS/PHONE 336 COLES MEADOW RD (413)586-0465 PROPERTY LOCATION 102 HAWLEY ST MAP 32C PARCEL 240 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: CONSTRUCT ROOF OVER FRONT STEPS&MAKE SMALLER&BUILD DOGHOUSE BULKHEAD New Construction Non Structural interior renovations Addition to Existing - Accesso1y Structure Buildinp,Plans Included: Owner/Statement or License 052460 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Commissi Signature of Bui ing Offici 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. 102 HAWLEY ST BP-2004-0538 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block 32C-240 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0538 Project# IS-2004-0759 Est.Cost: $6000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Harlow Builders 052460 Lot Size(sq. ft.): 9801.00 Owner: HEBERT PAUL JR Zoning: URC Applicant: Harlow Builders AT. 102 HAWLEY ST Applicant Address: Phone: Insurance: 336 COLES MEADOW RD (413) 586-0465 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON:11 110103 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ROOF OVER FRONT STEPS & MAKE SMALLER & BUILD DOGHOUSE BULKHEAD 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• Receipt No: Date Paid: Check No: Amount: Building 11/10/03 0:00:00 6481 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo