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17D-058 (9) � Ml ro ( �.SttA14PT0 .� 0 a B 8 Gri"fj� x1f 'Na't4aillpftm Bi3ERC}I ItE[11E e Vl - 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