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17A-056 (2) I (Mill of Nlarfljaliip�ml - 6 �[5OR(Ii Its rtIs DEPARTMENT OF BUILDING INSPLCI'IONS 212 D1al Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFF DAVIT with a prVicipal place of bushmsdresidence at f -- - ------------ do Hereby certliy, moor tI c pains ;id ynalkes Oi t)P.Ipuy thm I an an employer providing the following, .�.,oike&s comnensnimil coverage or Iny employees working on tllis job: onam ma: Compaq) (_Police;Numb--r) (Lxpir--tlon Date) O I ant a sole proprietor, general contracro; ur homeowner (circle one) Pad have hired the contractors listed below who have the workers compensatiorn policies: (Name of Contractor) Dal) (Name of COP.traCior) UPAUMDA ( O:;I:;1:iY1� 0 1Ci NIIII]trr) (t:XiilrailCn D2IC) (Name of Contractor) jwurallcc C0nr:2nyiP0liq; Numbxr) (I=x;:.ratio Date) ---- ---------- - (Name of Contactor) (InsurjIC Coral;:_�Iy[!'oEcy Numi>^cr) (F::pi mmn Date) i I mll it solo lirop!ietol i'.IIQ have no or t0! II?e. �• ) aln a home ovine: perforl111I1� <Ll No"n":plc-ac be aware that ws ilc tx<nco t1r a :�c p!cry 1r::r to<gr_.v casncS a:.rt cc m cr air,<<,Iyc<n._ i cl!i c!` not InCYe thin dice waits ocr:`..U _..:i zpputtcr•�t Lccto r c txt�e rsall}'c r.:: rcC:c h ca ployc� xics t}�c twr cts ar��sstirn (GL152 31(S)).zrFli�aticn by a homcot��rr fora heave cc legal rtatua of an omployor under tLo Wcxkcr'i C x s{xrnal on A_CI_ I undo.-Y wd this a cony of O},-ctatcn:cnt nuy bo for-­d-1 to tt;o of l;---o for ttn covet-age vaifiealioo and that fail=to!stye mvtt-n90 tu:3:r 25A of MaL 152 can Iced to tho i'll—ifian Of rinir l mtalt:u cbmi ig of a ftne of up to.S 1.500.00 att'Jcx i.^.:+riu a tic: of tip to cn year n:�d civil txnnl6cl in dx f<�rnl of a strt W cry On: !Lrd a f to of S I00.W a dsy igtinM ar_ 6*4 Lot For dq;utrtxi Cil trio qtly f� - pc?mit Ntunbcr Slgnaturc of-I.tcc-:; cJfcrm;ttr, ?I-' I 3 i _ SECTION 8 k 00STRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑fin Name of License Holder : –7-0 0 wl W V C,CT `c, �l C S (3 -5 `2 s ' b Ae / License Number JJ Address Expiration Date T Cj �1 S97� � Signature Telephone Not Applicable ❑ Registered come, mprovementContractor: Company Name Registration Number 1 � � l ISio1 e ✓��► G i -g:�/C) Address Expiration Date 5 L�7 L� Telephone SE E' CTION 10 !WORKERS';COrAPENSATION 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....... ❑ No...... ❑ i o= ® x ner TO em 'ti :n' 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 fur 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 ►nay 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. I i Homeowner Signature i i .d yr' SECTION 5 DESCRIPTIONIOF0'PROPOSED WORK(checkfall3apalicable) w , p New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: r S �Q -e `1 5 C M' 15 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet D 66a`ffl New house and or ddition to eXi's'ting"=housing,:complete the followin : a. Us of building : One Family Two Family Other b. Number c, TaQms 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 cor�truction 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 . 11.`Septic Tank City Sewer Private well City water Supply SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENTOWCONTRACTOR APPLIES FOR BUILDING-PERMIT Pot U C �a r p�q S as Owner of the subject property hereby authorize 7^0^1 to act on my beh in all t;t e r I i o work au horized by this building permit ap lication. Signature of Owner Oate (9VI .7 `C{ /1 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. —1 ors Print Name Signature of Owner/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 X 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 of Northampton Sfatu Hof Per< tt• Building Department Crrb Cud/�r 212 Main Street SewerlS Room 100 rll v Northampton, MA 01060 T' oSets�of tr c a, s ' hone 413-587-1240 Fax 413-587-1272 P'o %Site Ptans � �. * APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address- 1d3 This section to be completed by office 4 Cl"'e S Ft Map Lot Unit A0,*1 10/1 z �A OIL) Zone Overlay',District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: : -JVA'/ A Name t) Current Mailm� r ��� / /� Teiephone Signature 2.2 Authorized Agent: -ro 401C Name( ``pS) Current Mailing Address: Signature Telephone SECTION-3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed b ermit applicant 1. Building (a) Building Permit Fee 2. Elec"rical (b) •: timated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 + 2 + 3 + 4 + 5) ��f 7. D O Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 1.231AKE ST. BP-2004-0344 G1S#: COMMONWEALTH OF MASSACHUSETTS AvfA:31ock: 1A -056 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0344 Project# IS-2004-0500 Est.Cost: $5594.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Quinlan Builders 053107 Lot size(sa. ft.): 22564.08 Owner: MARDAS PAULA Zoning`URB Applicant: Quinlan Builders AT. 123 LAKE ST Applicant Address: Phone: Insurance: 5 Hillside Dr (413) 585-0949 HADLEYMA01035 ISSUED ON.9129103 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP SLATE & SHINGLE 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: FeeType• Receipt No: Date Paid: Check No: Amount: Building 9/29/03 0:00:00 3681 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo