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17A-302 (3) 1 4gtW 1P�0 =$o s $ 9 6asst:cEtnsrtta DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORTER'S COMPENSATION INSURANCE AF { AVTT Oijperniittee) with a principal place of business/residence at: (phone#) (streei/citylstafr/�ip) do hereby certify, under the pains and penalties of penury, that ( an employer providing the following worker's compensation coverage for my employees working on this job: �,9�r`Z,. �s�,�/may r,✓� �'� G �Sr�'y? ��i G� (Insu as 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/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Coatracior) (Insuran(-- CompaDy/policy Number) (Expiration Date) (Name of Contactor) Gmsu=ce Company/Policy Number) (Expiration Date) (attach zdditiocial shed ifntr ry to include iaforaution pertaining to all axdr rs) i ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:ptcaac lx aware that whidc homco"ixri who crnplay periaw to do rnxn�oxzt,C.Oci err rrPair work on a of not more than thrca units in�c nch the lwn»oaver 1,=dca or oa the grounds appurttnani the:do arc n«ecnrnrly coax datd to be employers under tho tvockces Act(GL152—:51(5) appdcaEoo by n homoovma for a liccase cc permit may evidcnx the legal status of an employes under the Woric.ele Compoonation +eL I understand that a copy of thin statrmmi m.y bo forwarded to tho DcQwimcod of Aoci&-&Offioc of Inzrirsnco for the coverage vaificatioa and that failure to accrue oovctago under section 25A of MOL 152 can Icad to the imposition of criminal pcnali(cs 00oustmg of a fmc of up to S 1,500.00 and/or i nprisonnxat of up to one yew and civil pcaalti a in the form of a Stop Work Order and a find of s 100.00 a day against tae.. Foe dqi uinl er city Permit t N Number MaI Lot# ,,,'.: Signature of Liccnsee/permitfee e SECT'ION,$3z C'ON5;�Rl�ClO�N S`ERVIC�S � ���� 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder —7 License Number Address Expiration Date Signature Telephone rR Not Applicable ❑ / a 1 s32 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 affica will result in the denial of the issuance of th building permit. Signed Affidavit Attached Yes....... No...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie 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( 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 ' I ss� Ji-�vy'r� SON 5 DESCRIPTION OF PROPOSED WORKS{c EC TI ik allanalicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: ��� S �4 A,y Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative F] Renovating unfinished basement Yes -° Nq Plans Attached Roll ❑- Sheet❑ ..If a ew ho see-a" d or acldit'on to exls 1 ff o MM—ft comILIble thM-0J '0"WJb !: 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 ,K! i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes 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 t3UILDING PERMIT as Owner of the subject proper hereby authorize to act my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, , 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. ��E' �i'trE✓J�`� Print Name Signature of Owner/Agent Date 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 �1 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: rr�, f----- of Northampton k at - t� i ding Department Curb emu`It 12 Main Street :Sewe p a J�; i Room 100 1NaterlWei1 1 _ AR 2002 i Two,S ,'ampton, MA 01060 y. :6 ° a• 3-5 7.1240 Fax 413-587-1272 �51te APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORATI MON Thii I.J. Property Address: $ � j Map of .. r Elm istnct � ° � CBS i r cf" fi£ SECTION 2 - PRO PERT-Y OWNERSHIP%AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing ddress:�8�s S� — .� Telephone Signature 2 2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION;'3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Uso Only completed by ermit applicant 1. Building Summa (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 PermitNumber: . Date Issued: natu ee Building Commiss•IR er�lnspector of;BptJ,d�nBs Date, :S HILLCREST DR BP-2002-0823 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-302 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2002.0823 Project# JS-2002-1373 Est.Cost: $5000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Roy Omasta 101533 Lot Size(sq. ft.): 21867.12 Owner: TURNER DAVID S &MELODIE P Zoning:URA Applicant: Roy Omasta AT. 115 HILLCREST DR Applicant Address: Phone: Insurance: 21 North St (413)247-5666 Workers Compensation HATFIELDMA01038 ISSUED ON:411102 0:00:00 TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER SINGLE LAYER 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 SiEnature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/1/02 0:00:00 12666 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo