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25C-197 (2) i 11 1 r t ) x } f i } I r - r ! e t/�u _ z } y i : 4-�1tAMpTO 4 B _ j�lasaACf[ttsrtta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 , WORKER'S COMPENSA'nON INSURANCE AFFMAVIT with a principal place of business/residence at: ��r�4=v��,C%�=L ��', l v?`; V '�4�(phone#) y��'<} 'C%C (•-�sy-„t/cih',''statl-�aP) C� !cam�j �� � _ ��i�t=t � C 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: (lnct=aa Company) (Poky Number) (Expiration Date) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed(elow w wing worker's compensation policies: (Name of Contractor) (Znsurancc Cornpauy/Pclicy Numbcr) (Expiration Date) (Name of Contractor) (Laurance Compmy/Policy Number) (Expiration Date) (Name of Contractor) (Ins=cz Company/Policy Number) (Expiation Date) (N e of Contractor) (Insurance Company/Policy Number) (Expiation Date) (attach 'oaal r15cci if nocczsiry to mchlde infonaut con pertaining to all ccatmaori) 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 awart that while homcowncca who ploy perzons to do 0j3_i0+z*•j„r cva ucxion or repair wocic oo n dwelling of not meet than throo units in which the homooavcr r=dcs or on the wounds appurtc�then t arc Dot Ccncrtty wasidacd to be nPloyrrs under the work 'o=Tc zsation Ad(GL152,ss 1(5)),application by a hotncowoa for a lieeax a permit may evidcnoe the legal ctnhrs of an amployor under tho Workcex Comp.Ation Act_ I understand that a copy of thin rtatcmcni may be fotwnrded to tho DcperimcaQ of Indi-ibial Accidca&Offioo of Imrusnoo for the coverage verification and that allure to scatre coverago under scetioa 25A of MOL 152 can lead to tho imposition of crimin Penalt:ea oonsisting of a fine of up to S1,3OO.00 and/or imprisotxma of up to one year and civil peualtics is the form or a Stop Work Otdtr and a find of S1OO.QO tgainst t 1 4Forr deps:Nuwmber tsl tuo Doty pt.nntMap4 lot 4 f Liccnscc/p't.tt'e LbLe SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Apppplliicaa�ble ❑ Name of License Holder : ±_��� r /T i � 14L,1 �' �3 r License Number , Address Expiration Da e Signatu Telephone WHOM L a :.: , ,, Not able ❑ r vemen n r r. ," 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ �11� ,aHome��� caner EXeniptuon 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 t , SECTION 5 3'QESCR IPTION_:O "P.ROROSED YVORW cli'eck all.a" `li"cable 3, ,�hzgvilm*.,µis,..eN u S rvap;4Sd.3?c;F 9'p .3 af ., ; r New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: rc�n�' t L I ' acy���t' — i2 t rp O UL g g bedroom Ye Alteration of existing bedroom Yes No Adding new bedroom Yes [-s'" No f Attached Narrative 0 Renovating unfinished basement Yes _I,, No Plans Attached Roll o - Sheet 0 GCENew�to sea�d�oraii8ition.to-ezistng�lioius�ngcomete fhe fol'lowinn a. Use of building : One Family --C� 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 OVYNEOSS;, GENT`OR'CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authori e _ I to act on my behalf, in II 't e ative to work authorized by this 6uilding permit application). ( r, c� Signature )Cnf r Date as Owne({``%Authorized Agent hereby declare that the statements an information on the foregoing application are true and accurate, t& AZ-best"ef,my knowledge and belief. Signed under the pains and penalties of perjury. Print NamV'4'�—e Signa Agent Date f r 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 Sp ial 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 wa7er or wetlands? NO y r 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 .a/ 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: tatU9 ��_ � ; Glty of Northampton N' a ! Building Department Ourb�Cctt } � s , .-21,12 Main Street Sewer�SeP,Ila° i �.rl ^ ,;, I. �' ° Wa erJWell q, z Room 100 r I North 'mpton, MA 01060 Two Sets ofi S ruct . � � I phci"rte 4`13 58 1240 Fax 413 587 1272 Plot/Site Plans�� y � 3 s i C K aro e Other�Speclfy �do APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SEA CT10N 1 - SITE INFORMATION �— — This section to be completed by office 1, 1.1 Property Address: n �, � j/ Map Lot Unit 'J Zone Overlay District 1 V Elm St. District'_ CB District I SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: , -Vl 57 Name(Print) 4L Current�Mailing Address _ elephone — ----- - Signature 2.2 Authorized Agent: `. �'�.� f V U6C-f0 Name ri t Current Mailing Address: S' Telephone _ CTION 3 -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only COMID leted b ermit a licant 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 = (1 + 2 + 3 + 4 + 5) j f7 d Check Number SU This Section For Official Use Only Building Permit Number: Date Issued:- Signature: Building Commissioner/I spector of Buildings Da 6e T. BP-2002-0932 CIS#: COMMONWEALTH OF MASSACHUSETTS 191 CITY OF NORTHAMPTON Lot:-001 Permit: Buildina Category: BUILDING PERMIT Permit# BP-2002-0932 Project# JS-2002-1509 Est.Cost: $5500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R JOSEPH MURPHY 059333 Lot Size(s4.ft.): 6403.32 Owner: CREELY ANN&BRIGITTE PAROT Zoning:URC Applicant: R JOSEPH MURPHY AT. 65 NORTH ST Applicant Address: Phone: Insurance: 65 RESERVOIR RD (413)584-1515 LEEDSMA01053 ISSUED ON:4125102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL LIVING RM, REM NON BEARING WALLS 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 4/25/02 0:00:00 579 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo t,4^'�l IN x f 65 NORTH ST BP-2002-0932 GlS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 197 CITY OF NORTHAMPTON Lot:-001 Permit Building Categ=: BUILDING PERMIT Permit# BP-2002-092 Project# JS-2002.1509 Est.Cost:$5500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., Licenser Use Group: R JOSEPH MURPHY 059333 Lot size(sa ft.): 6403.32 'Owner- CREELY ANN&BRIGITTE PAROT ti 7�-194e:URc Anpliiant: R JOSEPH MURPHY 65 NORM' Apolicant Address: Phone: Lksgranggi 65 RESERVOIR RD (4131584-.1515 LEEDSMA01053 ISSSM ON:4125102 O:U .tIQ TO PERFO M THE FOLLOWING WORK.-REMODEL LIVING RM, REM/NON BEARING WALLS POST THI§CM VISIBLE ERQM In STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter. Footings: Rough: Rough: :q 10� House# Foundation: f ` lj't!` Driveway Final: Final: Final: (l o2 00 Rough Frame: } Gas: Fire Department Fireplace/Chimney: Rough: Oil: _ _ -insulation: o 5 1p-po2,� Final: Smoke: Final: 11K 6 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPWNW11ATI N OF ANY OF ITS RULES AND REGULATIONS.` , Building 40101 0.00;41ft 579 212 Main Sbve%Phone(413)587-1240,Fait:(413)557-1272 Building Comm�sioner-Anthony Patillo a