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17A-078 0.�1vJfPT �0 g E 11Tf-) of �\To f 11allip1011 �- 4 � E Rla:3 _= tnc h n ccl la' o DEPARTMENT OP DUILDP�C INSPECTIONS _ 212 Main Strcct ' Municipal Duildinl, Northampton, Nfass. 01060 WORICER'S CO'MTENSATION LNSURA_NCF AI TMAM' (litxuscc/pcnnittcc) ---- - vAth a prLFIcipal place of business/residefce at (sure tl6 ty/slatcln p) do hereby terrify, under the pptns and penalties of perjury, .ha (4C) I an an employer providing the following worker's colnoens::D0 , cove,,ye 'of Ind eluployccs worlDng on ulis job NIUMC 2-1 (Iasu =.(-- Cotar.y) (PoUc-. NtL-nirr) (r: irrio„ Dat ) ( ) I am a sole proprietor, general contractor or homeow-oer (circle o:le) amd have hired the contractors listed below who hzve the ioHo%VinQ Worker's policies: (Nnivc of Co l�:-�!cto-) (lti_suranc: Colnoan)fPcuc Nu.mb_r) (Name of Contractor) (Ii-s-Li aocc ComDa N,iPoticw Numcrr) (ExTU-Ziion Date) (Name of Contractor) (In_surancc Comp2n)-/PoUcy Nnmbcr) (Expirboo Dale) (Name of Contnctor) (Lasuran� Company/Pohcy Nmntrs) (Expuauon Datc) (arlact3�d.i;;«:il c'_kC.if❑cc�ci.� to inc_�udv inforta.�oo patai.nins w.11 c«rrr_o�) ( ) I am a sole proprietor and have no one worling for me. ( ) I am a home owncr performing all tlae work myself. NOTE.Plr_sc be ewarc Ole IU-0 bca3eowvcf�wbo employ pc Lo w do cr repair.,ork of onl Mort ttvo tf:ro:tmmts in«;a ich the lwfnoowacr wide or cc the Qvuorr..�apputict.M the "not Gam"*=ally cot d! -�d w be employe rvx c the-K� r1z or :t m ntt(GL12 31(5) anpbcn6cn by a hcmcowOa fcr c c _a perm t r=y c Aden«tl:e Icga.l n,^r of nn c=;Iloyor uodcr din WOft'q-t Compoo,,-Li Acs- [uodeni.tnd did a Dopy of thi.rt-.f—may tie roc--dnd to tbo popo.t--,r of lndaitriel Arad—&Offioo of lruu�fof tha oov=gc vaif ralioo and t1Lr L1ltTC to tomm bovcfnsc tmdcr soulop 25 A of MOL 157 on la.d to tlx i=,ositioa of airmail pcoawcs 000iismg of a Uric ortW to S I}00.00 eodfot iM�i of up to one year and Civil Pauluc n tC form of n Stop Work Order Mad a fim of 5100.00 t day tplazl me ra dcp.fun--",t—Drily Pool,Number Lot Signatu LicrsccPcrnittcc e�i / s SECTIONS-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ^� License Number Address Expiration date ,,— �, L,>1 Signat 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 of the building permit. Signed Affidavit Attached Yes....... K 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 SCCT]ON S- DUCHIPT1914,OF Mf,OED MRK ObAck all applicabi New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing A„ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Yi O�x.i--h VI fbCs �> mcO-�Ar)cd; rl�AC\ `�lT• Q`'�D�Aal A —� ) Alteration of existing bedroom Yes No Adding new bedroom Yes No y1 Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ Sheet❑ 41 CCJL. 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=`OWMER AUTHORIZATION -T&BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT !. as Owner of the subject property hereby authorize I�ie+�C11�1 �'� t–i-'+`��v to act on my half, in all ma ters relative tow rk authorized by this building permit application. Signature of Owner ate ' as Owner/Authorized Agent hereby eclare 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. Pri t Name / r D Signature o wner/Agent to V 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: t I!'^� � '��p .Gjy of Northampton E 1�,.''' L5 U twil Department ain Street m 100 AUG 0,Aort ton, MA 01060 oE�tnfR ne 413 8 1 40 Fax 413-587-1272 vnntt+ VI ►NSP 90IiIS APPLICATION TO , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-.SITE INFORMATION r ' Th�s�seO i oe'omp�le ed b 'DEEM 1.1 Property Address: "` a r y ' /� i lJlJi J'1...{1 1 1+° wi .y9� t. _ rIr X 7— -- err /.l �r' F� sy aL j s SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam (Print) CLg t Mailing Ad e s: l ` � t Telephone Sig tore 2.2 Authorized Agent: r� Name(Print) Current Mailing Ad r ss: Signatu Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS; Item Estimated Cost(Dollars)to be Official.Use Only completed by ermit applicant 1. Building Ll (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 6. Total =(1 + 2 + 3 +4+ 5) Check'Number This Section For Official Use Only Building Permit Number: ' Bate Issued: Signature: Building Commin slenertlnspector of Buildings Date st BP-2002-0128 GIS#: COMMONWEALTH OF MASSACHUSETTS .� CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofing BUILDING PERMIT Permit# BP-2002-0128 Project# JS-2002-0184 Est.Cost: $4400.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Cyrus Newman 064690 Lot Size(sq. ft.): 9757.44 Owner. MALINOWSKI DOROTHY R Zoning:URA Applicant. Cyrus Newman AT. 30 CAROLYN ST Applicant Address: Phone: Insurance: 697 Bridge Road (413) 586-1093 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:811101 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF 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 Sienature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 8/1/010:00:00 2723 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo