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17C-114 (4) 4 o 6lxsaxcflnactis' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFI DAVIT (licenserJpermittee} with a principal place of businesslresidence at: (phone#} (strret/ci ty/staf&2j 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: (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 Nu.mbtr) (Expiration Date) +r +r (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Pohcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necczary to ine}ude infix-marion pertaining wall ooatrado,$) ( 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 while homeowners who employ persons to do mairtmance o=studion or repair work on a dwelling of not more than three units in which the bomoowacr r=dcs or oa the grounds appruu=r1 thereto arc not geociaky considered to be employers under the worica's oam}xssation Act(GL152,m 1(5)} application by a homeowner for a license or permit may evidence the legal status of an employee under the Wotkees Compemation Act l understand that a copy of thin stnremeni may bo forva w to the Dtpwtmcat of lndmtrial A=4=&Oihoc of hzsurwoe for the ooverage verification and that failure to se coverago under soction 25A of MOIL 152 can lead to the imposition of criminal penalties oomisting of a fine of up to$1,50o.00=Woe of up to one year and civil penLhics in the form of a Stop Work Order and a film of 5100.00 a day against me. For departmmcnl use only �1 Permit Number Mall# Lot# r° _. Signab=of LicensedPermittee e SECTION 8-,CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder License Number Address Expiration Date Signature Telephone 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 the building permit. Signed Affidavit Attached Yes....... V No...... t y �� «, Ift 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 responsibilit for compliance with the State Building Code,City of Northampton Ordinances, State a o 1 Zoning Laws and to Massachusetts General Laws Annotated. Homeowner Signature i SECTION 5- D TI 0 P 0 + D' O RK(cherk all a rc b De New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Ml-**' Or Doors ❑ Accessory Bldg. ❑ Demolitions ew Signs [ ] Decks [ ] Siding[ ] Other [ ) All.4 Brief Description of Proposed Work: Alteration of existing bedroom Yes_'No Adding new bedroom U Yes °� No Attached Narrative❑ Renovating unfinished basement Yes P' No Plans Attached Roll ❑ - Sheet❑ i, 1 die fo t' a. Use of building : One Famiiy 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 AUTHORIZATION -TO BE COMPLETED WHEN OWNIERS,AGEWJ BR.CONTRACTOR ES FOR BUILDING PERMIT l a fib as Owner of the subject property hereby,a4orize to act on my be; if in all atters rela ' e t work authorized by this building permit application. q 30 - 00 Signature of Owner Date -em 9w er/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-9wrw/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning 6� r,A This column to be filled in by Building Department Lot Size le 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: City bo thampton "9 Buildin9! apartment y 3 1202 Ma, n Street s. Room 100 Northampton; MA 01060 l"one 4J`3.587-1240 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 Address: This sectionfito mpleted by off ce IN fs 'Ma � rot unit 5�►1so Rye. p �- ((7�PYl co, © (� �— Zone jvuea lay D! � Elm St. District CB DlOrlct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: eA —7- k1 Na rint) Current Mailing Address: St` T Z(` 1 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 Use Only completed by ermit applicant 1. Building �/ o (a) Building Permit Fee 2. Electrical _____ T (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 Commissioner/inspector of Buildings Date File#BP-2001-0239 APPLICANT/CONTACT PERSON RICE ROBERT T&NANCY FABIAN ADDRESS/PHONE 50 STILSON AVE (413)586-2861 Q PROPERTY LOCATION 50 STILSON AVE MAP 17C PARCEL 114 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 Z cj Typeof Construction: REBUILD ROOF OVER EXISTING OPENPORCH New Construction Non Structural interior renovations Addition to Existin Accessory Structure B_uilding Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan TI-IFiFOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: (/ Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 rmit fpom Cons 6ation Commis io _Permit from CB Architecture Committee Signature of Building 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. 50 STILSON AVE BP-2001-0239 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 114 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0239 Project# JS-2001-0398 Est.Cost: $400.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Size(sq.ft.): 11979.00 Owner: RICE ROBERT T&NANCY FABIAN Zoning.URB Applicant.• RICE ROBERT T & NANCY FABIAN AT: 50 STILSON AVE Applicant Address: Phone: Insurance: 50 STILSON AVE (413) 586-2861 O FLORENCEMA01062 ISSUED ON.911100 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD ROOF OVER EXISTING OPENPORCH 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 Siiznature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/1/00 0:00:00 2654 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo