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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFMAVIT
I,
(limmSe&permittee)
with a principal place of business/residence at:
(phonell)
(strewcity/stalrlap)
do hereby certify, under the pains and penalties of peruuy, chat:
(4-6 am an employer providing the following worker's compensation coverage for my
employees working on this job:
(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 o Contractor) (Insuran Company/Policy Number) (Expiration Date)
if
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poky Number) (Hxpi-m6on Dale)
(Name of Contractor) (Insurance Company/Poky Numlr..r) (Expiration Date)
(aaach additional slscc Tnoocuzry to kwhidc informatioa pc taiuing to all wofraciots)
i
O 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 aw2rt that whilo homeowoera who employ pczzom to do mmat�c str c oc or repair work on a dwcU g of
not more than throe units in which the homeownc-resides or on the groins appurtenant tbe;Cto art no(generally ooasidcrcd to be
employCra under the wvrkces compensation Act(GL152,=1(5)�application by a homeovma for a liccase a permit may evidcnoe the
legal ctatua of an employer under tho Workxez Compemation ALL
I undessi.+,nd tbzt z copy of tlsiz ctatcmcot may bo forwmr<a to tbo Dcpartmm of Indust iel Aocidczty Olfioo of Insucioce for the
eovertge vaificatioa and that failure to secure covaago under soctioa 25A of MOIL 152 can lead to tbo imposition of criminal pcaalties
consisting of a fine of up to S1,500.00 and/or imprisoanxzzt of up to one year and civil pcnattia in the form of a Stop Work Order and a
fum of 5100.00 1 day tgniaA me—
For&Patin-nW uzo only
Permit Number
Lot#
Signature of License&Permittce e
r
f
ECtTIb 8) �LiNSUC1C1�ISERVICES
,..
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
e e n . me. me n ra y Not Applicable ❑
Company 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 affid�
will result in the denial of the issuance oft1he 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)famili(
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 persona
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, Stat d Local Zoning Law5)and State of M ssachusetts General Laws Annotated.
Homeowner Signature
s
yen . a $'p LEN
OTION SC'R' 4�ION JF�i ROPOSE� ►VtlR cti ck l licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ' Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: V az+ 1-J Cl\k RZ Fma'-& W
-.
Alteration of existing bedroom Yes � No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes l' No
Plans Attached Roll ❑ - Sheet❑
5 1'f New house and ar t dditJ0"Jo hWsink;complete%they;#.oll,o' i 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?
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
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
SEC TWA OWNER AUTHORIZATION TO.BE CONIPLTED .WHEN
w, aim
'N NT bR CONTRAGfO AppLIF5:F012,13UIL'bf PERMIT 11 -l as Owner of the subject propel
hereby a thorize to ac.
my be I , all mattes relativ to authorized by this building permit application.
Signature wner Date
11"��r-77-�— In�(1tf Y�I �� 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 u r he pains d penalti erjury. p
I 4
Print Name I^
rJ
Signature of Owner/Agent Date
1
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
—7 / Building Department
Lot Size f ,U �--
Frontage
Setbacks Front I O S cJ
ci
Side L: G R: L: R:
Rear .
Building Height 2-6
r
Bldg. Square Footage o7 %
Open Space Footage L` %
(Lot area minus bldg&paved L
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has Spe Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was thh rmit 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 o f water or wetlands? NO y 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:
w CEy rthampton
Kill, I epartment
DEC - ' ^^,�I
2 in Street
100
L- North mpt n, MA 01060
„7
-12 0 Fax 413-587-1272 a"
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -S"ITE INFORMATION
1.1 Property Address: This section too be comp"letedbyoffice
a( 7
7) Cliff A v
� a
Mp of h .
x
lv i 'F� f W� �C Zone Overlay Distrt�t' V* �
vim.
Elm'St.'District 'Cl District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
lam--cf
Name(Print) Current 11ail ing Address:
,<T 4 LIE
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION"3 - ESTIMATED"CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building 7 (a) Building Permit Fee
�U G
2. Electrical (b) Estimated Total Cosfof
Construction from 6
3. Plumbing Building'Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number r
This Section For Official Use Only
Building'Permit;Number: Date Issued:
Signature:
Buildmg"C6inmissioner/in5pector of Buildings
File#BP-2002-0566
APPLICANT/CONTACT PERSON EDMUNDS ROBERT L&GEORGIA P
ADDRESS/PHONE 63 GRANT AVE (413)584-2448 Q
PROPERTY LOCATION 63 GRANT AVE
MAP 25C PARCEL 098 001 ZONE URB
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: INSTALL BULKHEAD&REMOVE DIRT IN CELLAR
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y 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)GIATION 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
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.
AVE BP-2002.0566
GIS#: COMMONWEALTH OF MASSACHUSETTS
:Block:zsC_098 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0566
Project# JS-2002-0882
Est.Cost: $5000.00
Fee: $50.00 PERM[WONIS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin
Lot Size(ssq. ft.) 8886.24 Owner: EDMUNDS ROBERT L&GEORGIA P
Zoning:URB Applicant: EDMUNDS ROBERT L & GEORGIA P
AT. 63 GRANT AVE
Applicant Address: Phone: Insurance:
63 GRANT AVE (413) 584-2448 ()
NORTHAMPTON M A01060 ISSUED ON:12113101 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL BULKHEAD & REMOVE DIRT IN
CELLAR
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 12/13/010:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo