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asaSf ACl�nEfltE 1
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COM
PENSATION INSURANCE AFFIDAVIT
(Iicensee/permittee)
with a principal place of business/residence at:
3 WC
3u� 2,� S•r1444� pin (phone#) Sal
(st=Ucity/state/ap)
do hereby certify, under the pains and penalties of perjury, that.
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Com=pany) (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)
f.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inatrancc Company/Policy Number) (Hxpiradon Date)
(Name of Contractor) (Insurance CompanyRolicy Number) (Expiration Date)
(attach additional sheet if mcciury to inchide informltion pertaining to all coa!rn.dvn)
i
(Iaam a sole proprietor and have no one wolfing for me.
( ) I am a home owner performing all the work myself.
NOTE:plisse be awatc that whilo homoownaa wbo employ pazoas to do maint�co Grua oo or mpau worts m a dv--- i g of
not mace than thrco units in which the hornoowncr resides or oa the grounds apurunint ibacto arc Dot gcn=ffy coandcrcd to be
employers under the vemkcr'i.00mpe=aiiou Act(GL152,ss 1(5))�,application by a homeowner for a Li—oc permit may evidcnDO the
legal Ft2 uc of an omployec under the Worica�a Compomation Act
I undcrasnd thsi a copy of this rutcmcat may be forwarded to tho Dcpartmmi of In&u &l Aocidmt>'OESoo of la=—for tbo
oavcrage verification and that failure to saxtre covaago un dcr section ZA of MGL 152 can lead to tho inipos On of criminal penalties
owiLv rig of a fmc'of up to S 1,500.00 and/or bnpr6owncat of up to orm year and civil penattia in the form of a Stop Work Or and a
firm of s 100.00 a day against nx.
po.&ps, roW uuo only
Permit Number
• /4 DSO D 2.- P
s i of Li tree
S,ECT3ON 8-'CONSTRUCTION SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
} e n t Not Applicable ❑
;20 loa X-r %A-rN r
Company Name Registration Number
( By L-T- b�(ota3
Address n�1 Expir do Date
UJOE: 'rY1 n �
� h Y 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 Employet.5 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 anyl Loca orufig Laws and State,of Massachusetts General Laws Annotated.
Homeowner Signature
' TNI"SOf„N... Oif.S•o-.PROSED WOK(caeck=all aSECT plicable) "
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: S7D.06a- ZYH60 d _
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative❑ Renovating unfinished basement Yes V__'No
Plans Attached Roll El . Sheet V
sa�lf`Newho°u "e�ancioratltlition to eici'sting:h"ousing :-corrplefethe�followin�:
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 BE COMPLETED WHEN
OWNER S'AGENT"QR'CONTRACTORAPPLIES FORBUILDING PERMIT
as Owner of the subject property
hereby authorize �� Je1- /y• �J&.3 rd to act on
my behalf, in all matters relative to work authorized by this build;�'g permit application.
Sigrfature of�#f Date —�
I, obgxT 1 h 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 er th enalties of perjury.
/ 0 r u .�
P
ri rm
Signs ur of Owner/Agent Ddte
+ 4
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 7-. 962. Ac.Fronta e 4(06,00
�1
Setbacks Front A7V
Side L: R: L: R: o?J�
Rear 6;O,
Building Height
Bldg. Square Footage % 179
Open Space Footage %
(Lot area minus bldg&paved
Arkin
#of Parking Spaces
Fill:
volume&Location 0
A. Has a Spe 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. Are t re any proposed changes to or additions of signs intended for the property ?YES
No
IF-YES, describe size, type and location:
City of Northampton
17rf4l�npton ng Department
Main Street r
s ("1 �oom 100
NOU N MA 01060
?, phone 41�-58711240 Fax 413.587-1272 Sr
- AP-PNEATION-TO CONSTRV#T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,1 -SITE INFORMATION
This sectid'n o�be,' 'let c'IA1 office
1.1 Property Address:
Map lot�� X31
h Unit
Zonebr erlayDistrct
EIm St. District CB District
SECTION'2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name Pint Current Mailing Ad ress:
Tefephone
Signa ur
2.2 Auth ' ed Agent:
►RobIER-r y3 Zu 4q- we'ST(44yAFTzM
N rint) Current Mailing Address:
&A.� LD- iff 2 7 ' 2,q S 3
atur A Telephone
SECTION 3 - ESTIMATED C NS UCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
`� 2 O'ao• p�
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) Z.aUp• UrD Check Number Q 5--
This Section For Official Use Only
Building Permit Number: PU3 — !t Date Issued:
Signature:'
Building Commissioner/Inspector of Buildings Date.,
I � .
File#BP-2003-0457
APPLICANT/CONTACT PERSON LAGA MICHAEL R&ROBERTA G Q � �
ADDRESS/PHONE 148 MAPLE RIDGE RD (413)586-4326 Q }U
PROPERTY LOCATION 148 MAPLE RIDGE RD
MAP 36 PARCEL 272 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid_
Typeof Construction: ERECT 12 X 16 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 Stree ssion
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.
148 MAPLE RIDGE RD BP-2003.0457
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-272 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0457
Project# JS-2003-0779
Est.Cost: $2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor_
Lot Size(sg. ft.) 124581.60 Owner: LAGA MICHAEL R&ROBERTA G
Zoning_SR Applicant: LAGA MICHAEL R & ROBERTA G
AT. 148 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
148 MAPLE RIDGE RD (413) 586-4326a
F LO R E N C E M A01062 ISSUED ON:1118102 0:00:00
TO PERFORM THE FOLLOWING WORK:E R E C T 12 X 16 S H E D
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 Occupant Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 11/8/02 0:00:00 1028 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo