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17C-104 4�ttAMpT _0Oa a � �il43t Cl�ttECtIE" m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I-, (Iicensee/Permittee) with a principal place of business/residence at: (phone#) (street/city/stateJrip) do hereby certify, under the pains and penalties of perjury, that-. (v6 am an employer providing the following worker's compensation coverage for my employees working on this job: � �ri��.�'� 1 I�� 1 li�i� ��� 4.-\1 (•.. l" �f.,.<-�n r. j"..(�1�l,� -'/a�A'.�a l�.G"'�r (Insurance Company) (Policy Number) (Fxpiration Date) �;{; ?sYr ( ) 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) 0 r (Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date) (Name of Contractor) (Inwrance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (artadr additioml shed ifnecenary to include infotmarion pertaining to all coats ) ( ) 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 vehi]o homcowneca who employ pcssoru to do a&inj�coasuvction or repair work on a dvmiling of not maro than throe tarts is which the homeowner reside-or on the grounds appurtenant tb=w arc not generally considered to be employe-under the worker's compeamtica Act(GL152,ss1(5)�application by a homeowner for a license or permit may evidence the Icgal ctatrra of an amployor under the Worlceet Compomation Ad. I unduatand data copy of this ctat—ent may be forwarded to the Dcparrmmt of Industrial Accidca&Offioa of Insurance for the coverage verification and that failure to uxurt ooverag+o under soetiou 25A of MGL 152 can lead to tba im po$ on of au-31 penalties comisting of a fine of up to S 1,5oo.00 andlor imluisoamctti of up to one year and civil penalties in the form of a Stop Work Order and a f=of 5100.00 a day agai nt me. For d-p�use oily � t%' permit Number # Signature of Licensee/Permittee 'Mte SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number o -7 Address Expiration Date Signature Telephone Not Applicable ❑ si Company Name y Registration Number Address Expiration Date jJ Telephone. 6 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C( 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 5 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 P P' II appiicabl e New House ❑ Addition ❑ Replacern Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[1,] 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❑ 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 AUTHORIXATION -TO DE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT l �, °i,'_? /'� /�.!'r� ✓ := as Owner of the subject property hereby authorize Z—: '1='-t�'J r.-1 -�/' �'`� to act on my behalf, in all matters relative to work authorized by this building permit application. / Signa�f Owner Date I, r t%> iii j r 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 7 -, f; Signature of-Ow"af/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: - -- Northampton B I g Department Main Street R om 100 r,lNsE'EdSJ&%ham ton, MA 01060 h 40 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION s 1.1 Prooertv Address: t � �� �i 1!'�l V 1.1 f,f I j✓ opt� �,'. ##r- �%s l��/ � ✓� F..ks_"1 �irl� {• L..` ��t'I��— �1�I�x t�' r,, �A�ne �'a \ _ 4",.'v v v / `. .'s'�' -SECTION 2"..PROPERTY OWNERSHIPIAUTHOIRI ED AGENT 2.1 Owner of Record: Name Print) Currents j aiiin�Address: t- ,'( Telephone 1 01 Signs ure 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature ! Telephone StOPON 3 -OTIMATED CONSTRUCTION COS`E5 Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �.� u (a) Building Permit Fee 2. Electrical (b) Estimated Total Cast of Construction from 6; 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection �r 6. Total =(1 +2 +3 +4+ 5) Check Number p This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings date BP-2002-0188 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Cate og ry:replacementwindows/sidinc BUILDING PERMIT Permit# BP-2002-0188 Project# JS-2002-0292 Est. Cost: $12365.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sg.ft.): 8799.12 Owner: OLANDER WILLIAM P&DEBORAH L Zoning.URB Applicant: B & R Sidinq AT. 15 STILSON AVE Applicant Address: Phone: Insurance: 781 Bridge Rd. (413) 586-4167 Workers Compensation NORTHAM PTO NMA01060 ISSUED ON:8116101 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & 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 Silznature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/16/010:00:00 17806 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo