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17A-128 'T MA G1060 Z DGI X, vED-T In%, NIENT LE Tire staz? al-lows 'L"he honn�wmef the I-liziat-=der 7SOC-2ya 108.3.-,4r to ti a-c; -C r.:.`"� ­ :,-c,-. The szae, d•tfres who o-v;--z a 'des or ei:ds to be, a are or two _parc__�, o12 wrj he/she resides filmzil7 III -��s acot-sol- an&cr fa=- , s=cz—,Tes- d4w azzacLed orde-ached- f to sac�!,, = Person-w#0 Constructs More than one home In a twc-ye •-Period sLaJT not be cc ihorn_- f.-F the C-V Nor-Lh;: Dto -7,=-ts "--y erscra(s)who sedL to I y of n p -v4 — be ­- C tel eX�=pL.GZ, tO L1.1ei r 0 -i—E C r that by doLrz so vor. become responsible for complilamce with state buEdinz codes and re:Tjlafc=_ The i=eacuon prCceSs'reqL-71-reS that the boil-is;depwent be called' to ms-oe,_-, at cus st tages, wmch include foundation/footings (before bacIdEA sr,-notube holes rbefore vour), a raL,,sh buRdins-insvection(before work-is cc,r_ce:g�. reaulz-ed)aad-A f-Ing, h ding ims eg-tigm. The u;M-mg de ese ed- faEure to quires th , i=e_-tioms before the-work Secure these insvections can result fn failure to obtain a certificate of occuna.ncv LF the hcm ec-wan-_-hires.ozhiar trades -L 0 p e::o 7-ork(e,ec=call, plumb in g Has) tLe 11 o e 0 Ti w U.'r be resuC.nsble to r-�I-sz-,re that the trz-65s lire se---,,.ire their proper- per:. --ts L127 cozjuzct on to the buLldi=per=:issu-ed and that they get their required L-1-spectio ns-Farure of the L—d vi dual Modes to szeczye He pel='ZS and insP e--t'�Tons as e:� cz D Y',L t] such time as toe proper p er=--its and mspec-t.,ons are T7 de tie above- p.m. owne.-lreszident's signnture re-questing ele ptioi ca-!I to S,:Led,-,j_ail r-C-LIi e--i bLT;l "-z j -pecr,,jons necessary for the builds?p e"=I, Issued to me_ A r _ Office of Investiga!ions _ 600 Ti as?i ing ton Street ~^ Boston, .MA 02111 www.mass.g ov/dia V,Vorkers' Compensation Insurance Affidavit: Builders/C onto-actors/ElectriciansTILmbers A r-ollc2int information Please Print Leaibiti Name (Business/Organization/Individual): _ :7LL.11 eJJ. City State1Zip: jC i, Phone : __ 5.4, .`.re ,ou an employer? Check the appropriate box: Type of project(required): 1 i I am a employer with =� ❑ I am a general contractor and I 6. ❑ New cons—niction employees (fa and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ R--nodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. employees and have workers' 9. F7 Building addition [lv'o workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.F-1 lectrical repairs or additions I am a homeowner doing all work officers have exercised their 1 l.❑ Iumbing repairs or additions myself. ['-No workers' comp. right of exemption per 1VIGL 12. Road repairs insurance required.] _ c. 152, F1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] `Any applicant[hat checks box#1 must also fll out the section below showing their woricers'compensation policy information. Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors tl at check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy=or Self-ins. Lie. N: 00 b G � S-0 .Expiration Date: City/S S i : Job Site address: � ` _ tate;Zip: 0 1 � G Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for ' rage verfication.i I do hereby-cerri , unrtz;the pazns cr3rr erraitre e�pe,fax; iat the information provided above is true and correct 1�S i mature 7 _� —,�/ � Date-: ... 3 '-7 ---- Phone=: --- _= f town o fficiaL fCity or Town: Permit/License r I Issuing Authority (circle one`: _- Board o?Health _. BuEdiin_Dec"artmeat 3. Cir,lTown Cler:i -'..Electrical Ins pe:for 5. Pla m.0:n_ Inspector !I 6. Other II Phone Jr:ti t P .'Si)P:' SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ � Q Name of License Holder: \ (] / 9 _ Licen(-)Nu � mber � � Address i Expiration Date (0 Sig re Telephone 9.Registered Home In rovernentContractor „ „ , NdtApplicable ❑ Co r)anv N Registration Nummber� Ad ress Ex Nation ation Da e 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 bui4ng permit. Signed Affidavit Attached Yes....... No...... ❑ 11a- Home:Diner Ekempt on 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 1083.5.1. 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-vear 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks Siding[0] Other[Oj Brief Descri Rti p ed Work: � CJI� --r �� ti'y [��,�pv, OF'QOLJ- Alteration of existing bedroom Yes No Adding new'new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house'and or addition to ezistinA housing.complete the foI[owin± : 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. Masscheck 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 OWNERS AGENT OR;CONTRACTOR'APPLIES FOR;',BUILDING PERMIT v� N as Owner of the subject grope 0C� hereby authorize to act on e alf, in all matt s rel ive to work authorjzed by this building permit application. Signature of Owner 711 Date t as Owner/Authorized Agent reby dTcare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Sign under th ains and enalti s of perju - --- -� Print Signature f Owner/Agent Date Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front m Side L:,......._._. R. _..,._ L.'_._. Rear _ ._ Building Height _ --•-- Bldg. Square Footage _..... % Open Space Footage _„ _ % - - (Lot area minus bldg&paved parkin ) #of Parking Spaces Fill: (volume&Location) —• A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES __._._ IF YES: enter Book ,_ Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 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 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES,then a Northamptbh Storm Water Management-Peirnitfrom the DPW is required. s' . Department use only City of Northampton Status of Permit:. Building Department Curb'Cut(Driveway Perm it r r_f 212 Main Street Sewer/Septic Availability :Room 100 Water/Well ffvailabili�- - Northampton, MA 01060 Two Sets of StrudturaE Plans phone 413,x87-1240 Fax 413-587-1272 PlotJStte Plans Qtliei Speafyf APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION' 1.1 Property Address: This section to be completed by office l7rf-�c Map Lot Unit 1 Zone Overlay District Elm St District C6 District SECTION 2-PROPERTY OWNERSHIPJAUTHO iZED AGENT 2.1 Owner of ecord: �7 L CK a V t r i Name(Print Current Mailing Address: Telephone SigSu r e 2.2 Authorized A ent: V) Nam rint) Current Mailing Address U � � Signatur Telephone-T SECTION 3-ESTIMATED CONSTRUCTION COSTS° Item Estimated Cast(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building'Permit Fee 2. Electrical (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 Sec ion For OfficiatUse.Onl Date Building Permit Number. Issued: Signature: Building Commissioner%Inspectoro w rags' Date ;. 3151BRIl 1911%0` BP-2009-0704 GIS#: COMMONWEALTH OF MASSACHUSETTS a r .10 ::ilk w M e CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category_ BUILDING PERMIT Permit# BP-2009-0704 Project# JS-2009-001029 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 152172 Lot Size(sq. ft.): 11412.72 Owner: LAPINSKI EDWARD J&ANNA MARIE Zoning:URA(100)/ Applicant: BOB THIBODO ROOFING & SIDING AT: 315 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 O WC NORTHAMPTONMA01061 ISSUED ON:211812009 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL NEW RUBBER 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• Date Paid: Amount: Building 2/18/2009 0:00:00 $35.003208 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo