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12C-086 (3) ��tiAl rP�O 0 GXt� I# wart 11aillptoll s g B B �lxsaachnsctta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 �y WORICER'S COMPENSATION INSURANCE AFFIDAVIT je) X Pf Al &S (li censeeJperm1 ttee) with a principal place of business/residence at: (phone#) (streeilci ty/seatrla p) 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: (Inszrrance Company) (Policf 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) �c (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Pol cy Number) (Expiration Date) (Name of Contractor) (Imtlrance Company/Policy Number) (Ex-piration Date) (attach additional sxct ifnaxsszry to include iaformxtion pertaining to all cocftradors) ( I am a sole proprietor and have no one worldng for me. ( ) I am a home owner performing all the work myself. NOTE:please be await that whilo hcar_o-Ana-3 who employ perzom to coas:raction or repair work on a dwelling of not moce than thrco units in whictt the hotnoowncr resides or oo the Uvio At apputtcnsat tharto ere rnX gaxrxlly Dons tiered to be cmployrss under the wo;i c s motion Act(GL152-zs 1(5)�application by n hom00%-=for a Uccnc cc permit may evidcneo the legal aatuo of an employer under the Wociccea Compomatiou Act.. I undust=d that a copy of thix rutem may bo forwarded to tho Deyartmcut of Indus dal Aco&-&Of$oe of l—ursnw for the covaxge verification a d that Ed=to t==coverago tuner section 25A of MGL 152 can lead to the imposifion of criminal pcnslCes oomutiag of a fine of up to S1,500.00 andlor inxpriso�of up to oat year and civil pcniltia in the form of a Stop Work Order and a firm of s 100.00.day against mc. For dg artmrnul—only permit Number //B C Map# Lot# gnature of LicenseC/permitfee e SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder a A n Z?� J, Y5 License Number r` C S o 7 R' s ev i Address/ ,( Expiration Date Signature Telephone ., IMO rn r vemen n ra r. 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ J,T.w gommmeTwOw wnel r. eI1Clp.=Q fi 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 � ;SECTIONP DESCRIPTIONW PROPOSED WORK(check all aaallcable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: kem pub �G yob ,1�5O�rc �7� ��,ks%ter-'-��' �� y�k Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0- Sheet 0 6,51 fi New ho eva-id°or addition tbrdkisfi h—o-tasinrr=co`mple'te the f61I–O ry inR.: 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 SECTIOK7A-.OWNER"AUTHORIZATION -TO BE COMPLETED WHEN 0WNERS',AGENT:OR CONTRACTOR APPLIES FOR'BUILDING PERMIT n as Owner of the subject property hereby authorize _ "W!41 f'r _ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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 under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date y Y Section 4. ALL INFORMATION MUST BE.COMPLETED, or PERMIT CAN BE ft DENIED DUE TO LACK OF INFORMATION A 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: t 51 E C E i o thampton ------ apartment 21 n Street SEP 17 2002 100 Northa pto , MA 01060 e 124 Fax 413-587-1272 -o Ite a NORTHAMPTON,MA 01060 S�� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION ; This sectionA be completed y dfftce 1.1 Property Address: G �� Maps � Loi EIm St, District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Curren ailing Address: kAAict(A Telephone �`� � � -f � d®�� Signature (4 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 I (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) Check Number This Section For Official Use Only Building'Permit Number: Date Issued: Signature: Building Comm iss ioner/I mpector of Buildings Date„!. BP-2003.0264 t.1b.WK DR GIS#: COMMONWEALTH OF MASSACHUSETTS .' k: 12C-086 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category. BUILDING PERMIT Permit# BP-2003.0264 Project# JS-2003.0463 Est.Cost: $0.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN M. SOMMERS CS076875 Lot Size(sq. ft.): 10018.80 Owner: SURINER GERALDINE M&RUTH L S Zoning:URA Applicant: JOHN M. SO M M E RS AT. 20 RICK DR Applicant Address: Phone: Insurance: 39 SUMMIT ST (413) 323-6089 BELCHERTOWNMA ISSUED ON.9117102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE 2 LAYERS OF SHINGLES, REROOF W/25YR SHINGLES 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 9/17/02 0:00:00 2209 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo