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17A-072 (2) t r ' o4�1tMlP�O � e �lasartrilnsrut, DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building 'a Northampton, Mass. 01060 WOMCER'S COMPENSATION INSURANCE AFFIDAVIT (Iicenseejpermlttee) with a principal place of business/residence at: v a a-� /�� ✓t �, Ceti% +r> (phone#) S.2 -3A!5" (streei/city/ 2ip) 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: AA 0035 (Insurance Company) (Polio 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) (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) (attach additional sheet ifnecenary to mehsde infacmation p=uiaing to all ooabm o ) ( ) 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 while homeowncrs who employ pesaas to do mai tm-= constvetionor rcpai r work on a dwelling of not more than throe units to which the homoowner resides or on the grounds appurtennat then t are not generally ooaridcred to be empioyem under the vmdccft oampe¢saika Act(GL152,ss 1(5)),application by a homeowner for a license or permd may evidenoo the legal status of as employer under the Worlceet Compensation Act. I underataad that a copy of thin cut=ad may be forwarded to tbo Dcpdrwx d of rndustiel Acci4w&4ffioe of Iasurwoe for the coverage verification and that failure to secure coverage under section 25A of MOL 152 can lead to the imposition of criminal penalties oomistittg of a Tine of up to 51,500.00 and/or of up to one year and Civil penalties is the form of a Stop Work Ordr sad fmo of 5100.00 141Y spitut M For dcpatrnexta1 use only / Permit Number Lot# , u f;,_ t Of ermittee l OMAN OAMI M 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Hander License Number Address` Expiration Date 5 SignatureO Telephone r Not Applicable ❑ cz-u � G'v'a-*-,nom f C c� •-- � ? `� Company Nam �1 Registration Number tj O C c� 'L� �t A a '1` ct�v v� aY�- e ;;7-o "-1- —--2, Address t� Expiration Date Telephone " ° SECTION310 'A"A AllS'COMPENSATION�INSt�„RANCE'AEF1DAVi7(M 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(Wor ' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death)of the ss setts General s Annotated,you may be liable for person(s) you hire to perform work for you and this pe The undersigned"homeowner"certifie and ss e espo ibility for opipliance wi uilding Code,City of Northampton Ordinances,State and Vcal n' ws d S to of sachusetts Ge ral Laws Annotated. Homeowner Signature ,»gin New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: S otef �, c�t• ,cam moo- �-� �' y-�v.-�-. -�-G �'^t Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 11 Renovating unfinished basement Yes No Plans Attached Roll 0• 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_ pp 3 A N . y 4 as Owner of the subject property hereby authorize to act on my behalf, in all matters rela ive to auth rized by th' uilding permit application. Signature of Own Date as Owner/Authorized Agent hereby declare tha the statem s and information on the foregoing application are true and accurate,to the es of my knowledge and belief. Signed under the pains and penalties of perjury. 'k `- r*-/ /A 6if �Ct Print Name Signature of Owner/Agent Date W.. 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: w 1 City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587.1240 Fax 413.587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING '� ' .II at, 333 S�EGTION 1„ S1TEfNs ' RI1I «,N :.... . 1.1 Property Address: x, . a� SECTIOIN PRCIPERTY OWNERSFTP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pr�C4,41 Current Mailing Address: `i Est(- 7ff�d�s �Z �__ Telephone Signatur 2.2 Authorized Agent: CG Name(Print) Current Mailing Address: Signature Telephone 01W L`Q tTS Item Estimated Cost(Dollars)to be 0ffc[at completed by ermit applicant 1. Building �1 (a) Builtng Per� �E � 2. Electrical (t))Esttrted'� t� 3. Plumbing Bul`cttng Permit f;ee 33 v; 4. Mechanical(HVAC) u y� 5. Fire Protection ' 6. Total =(1 + 2 + 3 +4+ 5) Cl �taber _ 3 � .5 �.ct �. �n AV �ilr�lt �' � ;u �N kR;y"xr 35' a a� 'a dt � 1t3 bate fssueif nj * M a w q nx :; •' I KOK r- �gr#�a . 11t$ ! IeVF� ,� "�, D, S a 3' r � BP-2001-0892 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2001-0892 Project# JS-2001-1620 Est.Cost:$5700.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Larry Paquette Lot Size(sq. ft.): 11020.68 Owner: ADAMS RONALD S&DONNA C Zoning:URA Applicant: ADAMS RONALD S & DONNA C AT: 21 MOUNTAIN ST Applicant Address: Phone: Insurance: 21 MOUNTAIN ST FLORENCEMA01062 ISSUED ON:5/9/01 0:00:00 TO PERFORM THE FOLLOWING WORK:srtip and reshingle 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 Deaartment Fireplace/Chimney: Rough: Oil: Insulation: Final Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHXAPTON UPON VIOLAT N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy sienature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/9/010:00:00 2722 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo