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25C-193 - � B i � �� � �tassacEtttsctts �PARPAENT OP BUILDNG INSPECTIONS or, _ 2 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT (licensceJpermittee) with a principal place of business/residence at: (phone#) (atreet/city/stafdzip) do hereby certify, under the pains and penalties of peg'ury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees woridng 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 of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Polity Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (anach additiocal sheet ifnxmuy to mch)de informirioo pataiuing to all ooatradm) 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 whilo homornwm who employ pasom to do maint__�aac, washvction or repair work on a dwelling of not wore than throe units in which the homeowner resides cc on the groun6 apputteau t thatto arc not gencrally oomidcred to be employers under the wvriceez compensation Act(GL152,ss 1(5))�application by a homeowner far a Uccase or permit may evidcuoe the legal ctatuo of an employer under the W"kees compematioa Act I understand that a copy of thu statement maybe forwarded to the Dcpertaocnt of Indzrshial AocW-w&Offioc of lnsursnoa for the oovmge verification wad that failum to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penaWes eomistzng of a fine of up to 11,500.00 and(or imprisonmerd of up to one year and civil pemltia in the form of a Stop Work Order and a ' firm 0(5100.00 a day against mc. For depatnumW use cGlY Permit Number Map# Lot# k Si of Li erinit tee MET I� CO lip � e A v � ssaRs v m .», a t 3 t-- •°� ZZ m 0 7C Z o' a 3 o z o -a C m M o x y fD Zoning Miscellaneous Additions,Repairs,Alterations,etc. "feL No. _`'c Alterations 1 ..-NORTHAMPTON, MASS. 19 Additions ' APPLICATION FOR PERMIT TO ALTER Repair Garage 1. Locations Lot No. _,-2: Owner's name 2' Address19�r/'_ Builder's name Address'? �� -,-Mass.Constructio; Supervisor's License No. 1 C Expiration Date_.� 4. Addition r.- Alteration ell 6. New Porch 7. Is existing building to be demolished? 8. Repair after the fire 9. Garage No.of cars Size 10. Method of heating 11. Distance to lot lines 12. Type of roof 13. Siding house x/14. Estimated cosc- The undersigned certifies that the above statcmcnts are true to the best of his knowledge and belief. 7 Signaze o responsible appicanl Remarks - 10. Do any signs exist on the property? YES NO IF YES, describe size,type and location: Are there any proposed changes to or additions of signs intended for the property?YES NO IF YES,describe size,type and location: 11 . ALL INFORMATION MUST BE COMPLETED, or PERMIT C LIED DUE TO LACK OF INFORMATION. ef,ibblumn to be filled in ZSp hw Building Department I Required I Existing Proposed By Zoning Lot size Frontage Setbacks - frnnt - side L: R: L: R: - rear Building height Bldg Square footage %Open Space: (Lot area minus bldg &p6ved Parking! # of 'Parking Spaces f of Loading Docks Fill: -(volume -& location) 13 . Certification: I hereby certify that the information contained herein G is true and accurate to the best of my knowledge. ATE: L — i APPLICANT's SIGNATURE NOTE: lasumnoe of a� permit does not relieve an pplioant's b rden to comply with-oll Czoning requirements and obtain all required permits f m the Board of Health. Conservation ommission, Department of Publio Works and other applionble permit granting authorition. FILE # Q s r ' L 71 999 9 File No ,EPTOF U! PERMIT APPLICATION (§I0 . 2) PLEASE TYPE OR PRINT ALL INFORMATION Name of Applicant: �J Address 44�118--��9��- T elephoner � 7 � 4 Z. Owner of Property: Address: Telephone: 3. Status of Appiic caner Lessee Other(explain): —4 Job Location: Parcel Id: Zoning Map# '(� Parcel# District(s): _ (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5, Existing Use of Structure/Property L,f- Description of Proposed UseMJV r roject/Occupation: (Use additional sheets if necessary): 7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files. 8. Has a Special PermitNadance/Finding ever been issued for/on the site? NO DON'T KNOW L,-' 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# 9. 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: (FORM CONTINUES ON OTHER SIDE) 23 HIGHLAND AVE BP-1999-0620 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma :Blo :,..-° CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Category: roofing BUILDING PERMIT Permit# BP-1999-0620 Project# JS-1999-1181 Est. Cost: $3000.00 Fee: $20.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: James Roberts 117154 Lot Size(sq. ft.): 5749.92 Owner: ROCKETT ELIZABETH&M FARRICK Zoning_URC Applicant. James Roberts AT: 23 HIGHLAND AVE Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTON 01027 ISSUED ON:0110711999 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 01/07/1999 $20.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo