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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORT=R'S COWENSATION INSURANCE AFFIDAVIT
(liceusee/permitttrc}
with a principal place of business/residence at:
lu.ff G/ate hone#) 7-714C,.,
(str�et/ci ty/statr/a p)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worming on this job:
(Insurance Company) (Policy Number) (Expiration Date)
O 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)
�f
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compare}•/Policy Number) (F-\piration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(A-rh additiomi sheet ifnooc a to inc�infocmahoa pertaining to all coafta o )
'(> Lam a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plesae be aware that whilo hoamwncn who employ p=a=to do m inirnaacc coostucuon or repair work on a dwelling of
not a"c than throw units in which the homeowner r=dcs a oa the grounds appurtenant tha ao are oot gaxsally coandcrcd to be
employes under the worker's 000pcmatioa Act(GL152.s 1(5))application by a homoowncr for a liccase cc permit may evideam the
legal etatua of an-2ployoc underthe Wockoet Compwmd Art.
I understand that a copy of thin cEatemcai may bo forwarded to the Departaxat of 1.&,,b id Aoad-&Off oo of lawranow for the
cov=i&c verification and that fail=to secure coverage uoder section 25A of MOL 152 can lead to the imposition of criminal penalfies
oomisting of E fine of up to 11,500.00 and/or impzisoamwt of up to om year and civil penalties in the focm of a stop Work Ord—.and a
firm of 5100.00 a day ag&iwt mc-
Foe dgrartm�l u1O oaly
permit Ntunl�er
wo_ Lot
f m r, 4 rr P
c
a �
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
le°" sfere�dom�emproveme"'"n Con# actors ?;
EC fON °. ATIO 0 PO OP.OS
NOW 49k
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ��Sf/°�� Y—At-10 cOla— C.All"CCA--_9
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑- Sheet❑
sa� ff Tlew h""oi"se n`� or addit onVttbT,exi'sting�hous=in��p Je ffle01 wiJ�:.
a. Use of building: One Family_ y 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
NER�AU,� o�21ZATI0N TOBECOMPLETED WHEN S ENT � 1 N�#3ACTOR'APPIl P #2MIT
as Owner of the subject pro
hereby authorize to
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
J �Vi ck,/ �,- S r �L7 as Owne uthorized Ag ne f
hereby declare that the statements and information on the foregoing application are true and accurate, to the
knowledge and belief.
Signed under the pains and penalties of perjury.
,J
Print Nam
Sign f Owner A ent Date / —
j
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:
r► ,
{ --� (;� ►� ' ity of Northampton
ilding Department . r I
1 '��• r �'. 212 Main Street
l a
i Room 100 a
ANort ampton, MA 01060
P .
413-5 7-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S,ECTfON 1 -SIT E INFORMATION
This sectionto be`(;"O ted bywoffice
1.1 Property Address: 1
p� k§ Lot Unrt �
d 4 '•}'7xjr k
Y
Elm St. District 'CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:d
Name(Print) CurrentLMa�i�gA Address:
Telephone
Signature
2.2 Authorized Agent:
J Yt� r es�(— �S� Qr�YtGCIC ff 40e—,= �--S Wil
Name rint) Current Mailing Address:
`�--
gnature Telephone
'SECTION-3 -'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be OfficialUse Only
completed by ermit applicant
1. Building /G�CJ (a) Building Permit Fee
2. Electrical . (b) Estimated Total Cost of
Construction frdm.. -6
3. Plumbing Building,Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =0 + 2 + 3 +4 + 5) Check Number
This Section.For Official UseO,nl
s n
guildi rtg Permttlumber Date,•Issued
S��nature t
Buiidlrag Commissioner/Inspector of� ildirigs, fate,
t
$GARFIBLb AVE BP-2002-0800
GIS#: COMMONWEALTH OF MASSACHUSETTS
a`:Block: 17D-058 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2002.0800
Project# JS-2002-1343
Est. Cost: $1600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sa.ft.): 117 17.64 Owner: SHERMAN RICHARD K&KATHLEEN T
Zoning:URB Applicant: John Corbett
AT: 15 GARFI ELD AVE
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:3126102 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. 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/26/02 0:00:00 1289 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo