12C-054 Off(HAM PLO _
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORK M'S COMPENSATION INSURANCE AFFIDAVIT
Ncensec/permlttcc)
with a principal place of
business/resid ence at:
� _tfC-/ 7
(st�cet/ -/stairJzip)
do hereby certify, under the pailis and penalties of perjury, tliat:
(&)-� am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Las-=cc Company) (Policy Number) (Expiration Date)
I am a sole proprietor, general contractor or homeowner (circle one) and have hued
the contractors listed below who have the following worker's compensation pohcies:
(Name of Contractor) (Insurance Company/PoLiicy Number) (Expiration 1Datc)
(Name of Contractor) (lnsumricc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inatrance Compan y/PoLicy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(auarh adddioml shoot LfnoccTury to mc]udc infocmatioo p=jxm rig to all ooa5cdors)
O I am a sole proprietor and have no one wod ng for me.
( ) I am a home owner performing all the work myself.
NOTE:plcaac lx awarc that whilo hou"wncn who crnploy Pcsom to do rrz&iatca&n r_coostrU ioa or repair work on a dwelling of
not mote than throe units in wlrirb the homoova c resides of oa the gonads appiutatud thrxcto arc not wally oonndcrcd to be
employes undocr the worka'i ocavcssation ALt(GL152,ss t(5)�application by a homcowna for a ticcn-oC Peimd may cvkknoc flit
ltgal slitw¢of an employer under the Workorla Corporation Act
I uadasta nd that a oopy of thin riatcmmt may be forwarded to tho Dcpartwmi of lo&u .l Alta Offioc of for the
coverage venBcatoo and that failure to acatre ooverngo under sccUoa 2 5 A of MGL 152 can lead to th o in>posdioo of criminal PcaaW-
000sisOng of a fine of up to S 1.500.00 and/or imprison of uP to one year and civil penalties in th c form of a Stop Work Chdcr and a
faro of 5100.00 a day against me
For dcpartm�tsl use aaty
Permit Number
.tit c� �, 0 d t7 Map~I —Lot# —
Signat of LicenseelPc ee e
ECTION 8-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ��' "� '
License Number
, �AG� /`/c��� Ivy _ o 1-0.-7-
Address Expiration Date
S"F
Signature Telephone
Not Applicable ❑
Company Name Registration Number
1 !gf !� P-1 4�' 0t.;./ k'
Add7,6rrn ss Expiration Date
l Iv 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.
igned Affidavit Attached Yes....... ❑ No...... ❑
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
CTIO,�5 DESCRIPTION OF PRQ„POSED WQRK(check�)I ap lcable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New-Signs [ ] Decks [ ] Siding[ Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
-
Rib"' �exftffld k
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?
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
OWNERS AGENT OR CONTRACTOR,APPLIES FOR BUILDING PERMIT
1, 4 A tok5s� � as Owner of the subject property
hereby authorize 2- 1J#'p 40 ry ' '� � to act on
my behalf, in all Matters relative t work authorize by this building permit application.
Signature of Owner Date
�^ icI as tAuthorized Agent
C� tcj
hereby declare that the statements and information on the foregoing applicatiograre true and accurate, to the best:of my
knowledge and belief.
igned under the pains and penalties of perjury.
Print Name A
Signature of Owner/Agent Dated "
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 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 LIZ
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:
C
N",
ity of Northampton
40L Building Department
212 Main Street
Room 100 y
Northampton, MA 01060
phone 413-587-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property This secti6h t e completed by 4ffide
1/ �✓�UUc^ 4A lL S r Map lot rtlnit`
q P.
r/G rz z A) C, Z, rel /q' Zone prcerlay District
Elm St District C8-district
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame(Print) Curr t Mailin Address:
I// y
2 G _
�r/ Telephone /
Signature
2.2 Authorized Agent:
494,011
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted b ermit applicant
1. Building aj (a) Building Permit Fee
2. Electrical J� (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 ITU(p
This Section For Official Use Only
wilding Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings bate
I y
21 CLOVERDALE ST BP-2000-0987
*GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-054 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category:vinyl siding BUILDING PERMIT
Permit# BP-2000-0987
Project# JS-2000-1802
Est. Cost: $7713.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 7361 .64 Owner: WHEELER LINDA J&ROBERT J
Zoning:URA Applicant: B & R Siding
AT. 21 CLOVERDALE ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01062 ISSUED ON.5 18100 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL VINYL SIDING
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 5/8/00 0:00:00 17036 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo