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17D-028 (2) a OAT tiAM p?,O of 'Wart IJttmpfoil z 9 6 �asaachnsrtts -- <n DEPARTMENT OF BUILDING INSPECTIONS — 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 y �, WORKER'S COMPENSATION INSURANCE AFIIAVIT (licens�rJpermittec) with a principal place of businessJresidence at: 4 ►,. �o aJ rev" phone#} ��� ' 1167 (strczUcity/n f'/gip) do hereby certify, under the pains and penalties of perjury, tliat: (V�'l am an employer providing the following worker's compensation coverage for my employees working on this job: ji g«,ry &VI'VAI --4A)s63 Wcl'3;� -3ai' 77/--0)0 4 e), -jW (Ins C-- Compan)') (Policy Number) (1api rat3'0n Daze) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have lured the contractors listed below who have the following worker's compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Znsuran Company/Polio; Number) (Expiration Dale) (Name of Contractor) (Insurancr= Company/Policy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (ExTLmtion Date) (anarh additioail s cct ifineceu to include informsfioc pataiuing to nll condors) ( ) 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 awatc that whilo homcowncn who cmplay paiaru to do rnxjc��oxmtrucdon or repau work on a dwelling of not mono than throe units is which the lbmoovn re=dcs or om the grour�appurtem thereto ate no(gco rady cowidcrcd to be employcxa under the worka's oration Act(GL152,m 1(5)�application by a homeowner for a license or P=md may evidence tho legal status of an employer under d--,o Works x Compomation Act I understand that a oopy of this rtatcmcnt may be foewju d to rho Depart,,, t of Indau4ia!A=dmfs'Of5oo of Iivusnoo for rho oovcrage vrrificatioc and that allure to ac=re eovertrgn under sccuoa 25 A of MOL 152 can Iced to the iu>pos On of criminal pcnaltica 000sisting of a fine of up to S 1,300.00 and/or iaxprisoumc=t of up to one year and evil peaaitia in the form of a Stop Work Order and a fine of 5100.00 a day a&rinst tax. For dg ft=1tnl use only 3't f Permit Number y��o� Map# Lot# Signature of Liccn-scc[permittcc Thte ECTION 8-CONSTRUCTION SERVICES T 1' ,.1 Licensed Construction Supervisor: Not Applicable ❑ I Name of License Construction 601 A) L Cllr o License Number �2z 1,3R-1 -0 — c-)1- a ?- Address Expiration Date dO tC 4 70P) MA �� y��� Signature Y Telephone Not t Applicable ❑ Company Name Registration Number 1Z Alol2 06 -'/2;- �o6 / Addr ss Expiration Date x, 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. ,,01nQigned Affidavit Attached Yes....... IV/ No...... ❑ 4 ..........7"A_� 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 #0W TI C P h "' able New House ❑ Addition ❑ Replacem nt Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ Other b-U-4 Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - 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? 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 ;7—o x s1'%l as Owner of the subject property hereby authorize z;z %N Z• 12 4? LD- 61k'�P_ S� xJ `� -1 C-' to act on my behalf, in all matters relative to work authorizetJ by this building permit applicati . Sig ure of Owner Date L % ,�°�` as 9Authorized Agent hereby declare that the statements and infbrmation on the foregoing application are true and accurate, to the best of my knowledge and belief. OOLI-S under the pains and penalties of perjury. Print-Name 7 �— • �-�-�- ' 3 Signature of ff/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 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 Building Department 212 Main Street Room 100 � .. Northampton, MA 01060 phone 413-587-1240 Fax 413-587.1272 a Ya APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 7 This section trsbe comple#ed:by office 1.1 Property Address: --r�eA�.J ca C Map Lo w lJriit Zone Qrlay Dlsrtrkt t3 C 45 Elm St..District CB Djstrfct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: - ame(Print) � CuM Add Telepho ne Signatures/ T 2.2 Authorized Agent: y, Name(Print) Current Mailing AddrY ss i Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ?� t7j (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) 7 S °� Check Number a-,7— This Section For Official Use Only Building Permit Number: bate Issued: ....Signature: Building Commissioner/Inspector of Buildings Date � .. h 1 i 3 i i i i i a .I 63 STRAW AVE BP-2000=1059 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D-028 CITY OF NORTHAMPTON V Lot:-001 Permit: Building Category:windows replaced BUILDING PERMIT Permit# BP-2000-1059 Project# JS-2000-1900 Est.Cost: $8675.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sq.ft.): 18033.84 Owner: MERSKI FRANCES A Zoning.URB Applicant. B & R S i d i n q AT. 63 STRAW AVE Applicant Address: Phone: Insurance: 781 Bridge Rd (413) 586-4167 Workers Compensation NORTHAMPTONMA01062 ISSUED ON:5124100 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS 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 signature: Fee T- ype: Receipt No: Date Paid: Check No: Amount: Building 5/24/00 0:00:00 17063 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo