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17A-265 (2) GZfia of 'Hart aillptell M ae f�laeasritlrsrtta DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMT'ENSATTON INSURANCE AFFIDAVIT .censerJpermittee) with a principal place of business/residence at: Q T Ici�ce. �L� (phone#) `!/ (street/ci tylstate/ri P) do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees woddng on this job: (Insurance Company) (Policy 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) (Hxpiration Dale) (Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date) (atlach additiocaal sh�rc ifnoc,: y s tin i-a u informiIIoa pertaining to eft ox�aclon) i ( I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:plcsee be awarz that while homcowvm who mplcy pasom to do mx�.tm.nn axsrvaioa or rzpair work on a dwelling of not moce than throe units in which the homcowncr rczidcs or oa the grout hs appurtenant tha- o arc oo(gcncralty ooc-sidcrzd to be employrla under the worker's ooatpeas4oa Act(GL152,ss 1(5)),application by a homeov vrS for a Gocwe or permit may cvid-=the legal ctahsa of an employes under the Workeet Compematiou Act. I undct�d thst a copy of this rwxmcut may be forwarded to tho Depa t,c of ia1 Aoci O$oc of[naursnoc for the oovcr g verification and that failure to secure coveingo under soction 25A of MGL 152 can lead to the imposition of criminal pcae cs consisting of a fine of up to S 1,500.00 and/or kvrisoumcrrt of up to one ytw end civil p=W es in the form of a Stop Work OrC and a firm of 5100.00 a day tgrtiast me- For dcp:rtmcfal use only permit Number hbo Lot# Si of L' ttce e .t �'EC�TONB CONST�UCTION�SERVICI:S > 8 1 Licensed Construction Supervisor: f� Not Applicable ❑ Name of License Holder: �J�S� t r��m��� n-7 7 9 10 License Number Ll 6 Y_ JQ/6' 10 Address - Expirati n Date Signatur Telephone ""' -,' Not Applicable ❑ Iin r' emen n s / 74/ Company Name J Registration Number bc, SA P1 or c nce M4. cy /0 Address t��a Expir ion D e Telephone, �� '—e—/U �. 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 affid< 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)famili 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 persona 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, L I Zonin s and Sta assachusetts General Law Annotated. Homeowner Signatur � aWs I53d r �'�°`" S�EMMION D IPTil OF 1?ROPOSED WOA T ch c I , hcab e� ; %- 3 wa as eu r+uv. 3 rxx¢ na^xwxs w+ x�+w a 1 AR New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding W Other [ ] Brief Description of Proposed Work: �� `~ ` Alteration of existing bedroom Yes_��No Adding new bedroom l! y Attached Narrative❑ Renovating unfinished basement Yes _k<No Plans Attached Roll ❑- Sheet❑ 6' Ifi fie uo se n l o addition t eXistinm"" housin care"fete t"e foll:owihk: 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 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 OWNEWAUTHORIZATION I'TO BE COMPLETED .WHEN OYVN)ERS AGENT:Oa CONTRACTOR APPLIES R:' ILDIr�:G PERMIT as Owner of the subject proper hereby authorize ��' S�° ` ��'� 1 ` ��"4� to act my behalf, in all matters relative to work authoriz by this bu&Kng permit application. � d� I �21 G> Signature of Owner Date 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 Signature of Owner/Agent Date Section 4. ALL INFORMATION MIDST 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 ev r 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. ere any proposed changes to or additions of signs intended for the property ?YES _ No Are IF YES, describe size, type and location: City of Northampton Building Department 212 Main Street Room 100 a 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 SECTION'1 - SITE INFORMATION This,section to°be comple ed byo f ce 1.1 Property Address: 3" ttx —70 Lu`( Zone OyerlayDist tc# X y l�IoT-e Elm St. District CB D,istnct SECTION'2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Ad ess: p -)v1 r rT t e TelephonJ - � y a Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 -.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only com leted by ermit applicant 1. Building ! co0 (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 Section For Official Use Only Building Permit"Number: Date Issued: Signature: Building Commissioner/Inspector ofBuildings Date 78 OAK ST BP-2002-0664 GIS#: COMMONWEALTH OF MASSACHUSETTS NIap--Block: 17A-265 CITY OF NORTHAMPTON P=g: QurT lding Category: siding 'BUILDING PERMIT Permit# SP-202-0664 Project# JS-2002=1„036 Est.Cost:$2000.00 Fee:$25.00 PERMISSION IS THEREBY GRANTED TO: cm.Class: Contractor. License. � 411 JESSE MONTGOMERY— 077410 i e ' ':13503.6 Own$, rQM4,Q P��I L 1,P�L E C A,I+pucanr Jesse MontggMery AT• 78 OAK ST AVXscantAdkes Phone: Insurance. 46 ©ak Street ____ 413, 585-84820 FLORENCEMA01062 ISSUED QN.-ll221.02,O.00.-!O TO'PERFORAI THE FOLLOWING WORK,INSTALL SIDING ON GARAGE POST THI CARD. O`I IS`MLR FRO TU STREET mbi Inspector of P ung Inspector of'Wiling D.P.W. Bailding inspector Underground. Service: Meter; Footings: Rouge. Rough. House# Foundation: Driveway Final. Final:' Final: Rough Frame: Gass Fire Denastment Fireplace/Chimney: Rough: 0111: Insillation. Final: Smoke: Final: 0 f� -i7r,07 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF ANY OF ITS RULES AND REGULATIONS. erti iC a of c nC Si at re: Fee X e: ei t �; Date;Pafd: Check No: 3maa�I: Building 1122/42 0:00:00 1196 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patiiio i}