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<9 DEPARTMENT OF BUILWNG INSPECTIONS
212 Main Street ' Municipal Building
,o
Northampton, Mass. 01060 y
WORKER'S COMPENSAITON 1NSURA_NCE t AAVIT
(liceuscrJpemvttee)
with a principal place of business/residence at:
(5t�tici ty/staler p)
do hereby certify, under the pains and penalties of perjury, that:
O I am an employer providing the following workers compensation coverage for my
employees working on this job.
(Lasurance Company) (Policy Number) (Expiration Date)
O 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) (Lnsuranc-- Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Comnaay/Policy Number) (Expiration Date)
(Name of Contractor) (Lnsuranc-- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comp a- Number) (Expiration Date)
(attach additioail thc,=t tfnoccnAry to inchidc iafixmatioa pertaia ng a all a dsadnn)
O I am a sole proprietor and have no one working for me.
2�am a home owner performing all the work myself.
NOTE:picric be awarr that whilo homcow ocra who anplay parer s w miricl�cornra:tioo a rrpair work on a dwelling of
not more than tlit)Do unite in winch the homwwvcr reorder a oa the E uun i appurtcnaaf thereto e c not Scbmily oonsidctcd to be
rmployrrs under the veocka's cosiTcrsatico Act(GL152-"1(5)),application by a homcow=far a license cc permit may evidence the
legal ctx ue of an omployec underthe Woriroet Compcmation Ad
I uadcrtt=d chit a copy of this tut-rzt may be forwcuded to the Dcpartacat of Ioduarrial Aoadrn&Offioe of lu%uweo for the
coverage vaificatioa and iliac failure to&==covcrago tinder section 25A of bIGL 152 can lead to tbd impositiOn of criminal pcnalt:cs
consisting of a one'of up to S1,500.00 and/or impriso�icrit of up to one yc r and civil pcmttia in the form of a Stop Work Order and a
find of S 100.00 1 day against me_
For 6"'tursdal uio Only
•. Permit Number
Lot 4
Si of Liccnsce/Pcrmittce e
SECTION 8;=.;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�9 tR Q stered`Fliim IrriprQvement'Contracto'r Y, ,m „.. _ ; Not Applicable
�. ,u � s
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...... ❑
om ®wn��r ;e pion
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 —
SECTI PTION OF PROPOSED WORK(check afl aaplicable)
New House ❑ Addition ❑ Replacement Windows' Alteration(s) ❑ Roofing ❑
Or Doors 1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: PEpk/9cJE ( J V0 C1 r Gci $� rUthrg DG D�
Alteration of existing bedroom Yes t.,- No Adding new bedroom Yes �No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ - Sheet 0
SaIfNewhousea"ndor..'ad"dition"to exist�ng=fiousing,compte"tethefollowing:
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
SECTION 7a; OWNER�ALITHORIZATION - TO BE COMPLETED WHEN
OWNERS AG' TbR)CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
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.
Print Name
7ignatuP6 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 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:
V
f
I y of Northampton 5 at sf Pe f
(" Q ilding Department Curb Gu
i 12 Main Street SewerlSep to I a
Room 100 Wa e11r f va
OCT 10 2002
N' rt ampton, MA 01060 T� o Sets of ��E� ��� �a � �
_ph(.1 � 3 5 7 1240 Fax 413-587.1 272 PIo 1SIte P ans ��� � Own
�
t)1r DINC,INSPEL710NS Other Sp,c '
pEPi C, B ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section,to be.completed by office,
1.1 Propert Address:
Map Lot
ry Zone Overlay,Distnct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
, n(0 U 9 4 --
Name(Print) Current Mailing Address:
— �6 --- —
Telephone �� �' 7���✓
Signature
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 �o (a) Building Permit Fee
2. Electrical (b) E=stimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4 Mechanical (HVAC)
5. Fire Protection C
6. Total = (1 + 2 + 3 + 4 + 5) Check Number J 6
This Section For Official Use Only
Building Permit Number: b 3 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0383
APPLICANT/CONTACT PERSON FOURNIER RAYMOND P&CAROLYN D
ADDRESS/PHONE 33 GARFIELD AVE (413)584-4575 O
PROPERTY LOCATION 33 GARFIELD AVE
MAP 17C PARCEL 074 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE WINDOW W/SLIDING DOOR
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
iFO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissi
Signature of Bui ing Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
.`> BP-2003-0383
GIS#: COMMONWEALTH OF MASSACHUSETTS
4s774.: CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0383
Project# JS-2003.0647
Est. Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Gropp: Homeowner as Contractor_
Lot Sizee(sa.ft.): 12109.68 Owner: FOURNIER RAYMOND P &CAROLYN D
Zoning:URB Applicant: FOURNIER RAYMOND P & CAROLYN D
AT: 33 GARFIELD AVE
Applicant Address: Phone: Insurance:
33 GARFIELD AVE (413) 584-4575 O
FLORENCEMA01062 ISSUED ON.10123102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE WINDOW W/SLIDING DOOR
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 10/23/02 0:00:00 3233 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo