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17C-072 (2) 1 4�1PT0 B 6 �+tsaschnactta' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMTENSATION INSURANCE AFFIDAVIT (licenserlpermittee) with a principal place of business/residence at: (phone#) (&t=Ucity/stafdzip) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance 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/PoLicy Number) (Expiration Date) r. (Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/PoLicy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attac3t additiocal shoct if n6ocuuy to inctude infocmirioa pertaining to ell oodrettors) ( I am a sole proprietor and have no one working for me. (�) I am a home owner performing all the work myself. \NOTE:please be aware that whiio homcownm who employ persou:to do mamim,ncc con3truction ar repair wvrk ou a dwelling of not mote than LL-00 units in Which the hotnoov v resides of on tho grounds appurtenant iberdo arc cot gcocrany ooaridcrcd to be employes under the works caxrva>:4oa Act(GL152,ss 1(5)),application by a homeowner for a Ucrase or pcfn may evidence the legal stxtua of as employer under the WO&Ces Compomation Ad_ I understand thsi a copy of this rtatcmcui may be forwarded to tho Depertasco2 of Industrial Ac6dm&Offioo of In usnoa for the covauge vc ificatioa and that failure to so=coverago under soctioa 25A of MGL 152 can lead to the impositioa of-mmll pcnakics oomisti of a fine of up to S1,500.00 anNot imprisotm>wt of up to one year and civil panitica in the focm of a Stop Work Otdcr and a firm 01 5100.00 a day against me For dq-rtm a uao city Permit Number Malst t# Si »ite of Liccsxlpermittee e L SECTION$ C6"' RIlCT10NISERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : IV U \r— hn CL.I--) VNA License Number Address Expiration Date Signature Telephone - gig Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE,AFFIDAVIT(M.GsL. 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...... ❑ 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 % �; r , S CTION;fS 3D C�Rf O �+�FuPR POSED�VNOF�K� h ck�all3a licable KI' New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofin Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Wor Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll 0- Sheet❑ s" lete a fol la ri I-New O 09 MBLOW d_Xistinh0f i'hM a. Use of building : One Family Two Family /X 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 OWNERAUORIZATION TO BE COMPLETED WHEN OWNRSAGEN1O�CONRACTOR APPI_IS 1 ORBUIL'bING PERMIT 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 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 f Owne gent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO L CK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Font 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 X 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: _-_C*t of Northampton tng Department 212 Main Street r !�oom 100 NOV lLN wit rtipton, MA 01060 phone 413;5871240 Fax 413.587-1272 - ` A.RjUGATION-TO CONSTRUCif, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: g This sec:#ion#o bek plat r/ 4 d51v _ wfY =Maps ao y �rlay Des#r c EIm:StDist"riot � f� CBR stt`ict" ���`. x, SECTION,2-,PROPERTY OWNERSHIP/AUTHORIZED-AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone c.�--- Signature 3 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SEC710N.3 ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars) to be Official Use Only' completed by ermit applicant 1. Building , d (a) Building Permit Fee 2. Electrical `1 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) 9C) 6 . oo lCheck Number This Section For Official Use.Only Building Perin',it;Number; Date Issued: SDtur Bu,i ldmgrComrpissloner/inspector of Buihtigs, Date o ' AVE BP 2003 0451 GIS#: COMMONWEALTH OF MASSACHUSETTS 9 17312 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2003-0451 Project# JS-2003-0765 Est. Cost: $400.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor_ Lot Size(sq.ft.): 13634.28 Owner: MENARD ORVILLE E&NORMAN E Zoning URB Applicant: MENARD ORVILLE E & NORMAN E AT. 25 GARFI ELD AVE Applicant Address: Phone: Insurance: 25 GARFIELD AVE (413) 584-8218 O FLORENCEMA01062 ISSUED ON.11 11102 0:00:00 TO PERFORM THE FOLLOWING WORK:STR I P & S H I N G LE ROOF 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 11/1/02 0:00:00 302010 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo