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36-050 �CtUU1P . ,=o oy s $ GrZt� of 'Nart4aillpf ou z y..rtlaACl�ltSrttS m DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building 'o Northampton, Mass. 01060 WORKER'S COMPENSATTON INSURANCE AFFIDAVIT (license permittee) with a principal place of business/residence at: (phone#) �� ( ty/stalrJap) do hereby certify, under the pains and penalties of perjury, that. (kam an employer providing the following worker's compensation coverage for my employees working on this job: Z/f,FA2 T�Z <`' w�, 7-31s-:�'a/ �-e�'0 l�A (5 f (Ice 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 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) (anach additional shoe ifnecessary to iaclade information perhdning to an coatrecion) ( ) 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 aware that while homcownas who employ pc=m to do maimc suction or repair work on a dwelling of not more than throe units in which the homeowner residca or oa the groin apputteaaat thereto arc not generally 000ndcred to be employers under the worker`s con4x=atim Act(GL 152,Ts 1(5)�application by a homeowner for a license or permit may evidence the legal claws of an employer under the Workeea Compensation Act I understand that a copy of this statement may be forwarded to the Depwtmm2 of Indsutrisl A=dams'offioe of Insursnoe for the ooveaagc verificadoo and that failure to secure coverage under soction 2 5 A of MGL 152 an lead to the imposition of aiminal penalties consisting of a fine of up to S1,500.00 andtex imprisomnert of up to one year and civil penalties in the form of a Stop Work order and a find of 3100.00 a day against me. For dcpx tmr use only Permit Number v d' Map# Lot# Signature�e of Licensee/Pe 'ttee ti S.ECTI©N$-`CON STRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 'LeGJ License Number Address Expiration Date Signature / V Telephone M s � ���a..... . ...� Not Applicable ❑ —tea C--. Company Name Registration Number Address Expiration Date is s. ?e' ��� � �J a a 0?.J c3e 41 rrW 7i0 Telephone SECTION'101 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-.Dgg(;RlPTIQN,OF PBQPOSED MRK(dgck New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roo ng ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other[ ] Brief Description of Proposed Work: "— ' Nc j / N _-- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ -r� 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 SECTION 7a-OWNER AUTHORIZATION -TO RE COMPLETED WHEN OIWNER5-AGENT ORt,INTRACTOR APPLIES FOR'BUILDII+EG PERMIT I �ifj J A /n 61&1 as Owner of the subject property hereby authorize z�k» 4 L /�rr''/l� to act on my behalf, in all tters relative to work authorized by this building permit application. Signature of Owner Date ,�O>A) 4iJ asa2SW/Authorized Agent hereby declare that the statements and informs ion 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 Nam A. Signature of Owner/Agent Da 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: SEA 2 6 2030 City of Northampton Bilding Department �" t{� 12;Main Street Room 100 -=°�'�� Northampton, MA 01060 phone 413-587.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION,1.-SITE INFORMATION This section teraN% 1.1 Property Address: % — a Al c One $ECTION2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(PriM Curre ailing Address:. rn 61d �, / ,.. 7p- , Telephone , Signature 2.2 Authorized Agent: ,e�2 E. y Name(Print) Current Mailing Address: Signature Telephone S CATION 3 ESTIMATED CONATRUCTION!QSTS 7- Item Estimated Cost(Dollars)to be (Wicial Use Only completed by ermit applicant 1. Building 6� ... (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 All- 6. Total =(1 + 2 + 3+4+ 5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Co nmissioner/inspector of Buildings Date I 1I WHITE PINE DR BP-2001-0319 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma p-Block: 36-050 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:viWI siding BUILDING PERMIT Permit# BP-2001-0319 Project# JS-2001-0524 Est.Cost:$4800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Groin B & R Siding 100465 Lot Sizes .ft. : 1001 8.80 Owner: TOBIN WILLIAM F&RITA B Zoning:_URA Applicant. B & R Siding AT. 11 WHITE PINE DR Applicant Address: Phone: Insurance: 781 Bridge Rd. (413)586-4167 Workers Compensation FLORENCEMA01062 ISSUED ON.•9126100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING 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 Shmature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/26/00 0:00:00 17286 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo