12C-086 (3) ��tiAl rP�O
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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