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�iEEAt{IttbCttE
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 y
WORICER'S COMPENSATION INSURANCE ATTIEDAVIT
with a principal place of business/residence at:
7Z l yr�� 4 LL ko-
(strcet/ci ty/staf>_/a p)
do hereby certify, under the pains and penalties of perjury, that
I am an employer providing the following worker's compensation coverage for my
mployees working on this job:
► s d�66(A�;7 ► A- ��
(Insurance Company) (Policy Number) (Ex-piration ate)
( ) I am a ale ro rietor, general contractQpor homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
�-- mss; Co, X3830 �23
(Name of Contractor) (Insurance Company/Poticy Number) (Expirn on Datc)
(Name of Contractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Con=dor) (Insuran(-- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attact additional sl'xc ifncccsiu, to 6chudc iafbmutioa pertaiuing to all factors)
O I -un a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be awarc that whilc homcowoms who emplay pc=m to dJ rraintrn.a�oorx n c on or rtpair wors;on a dwelling of
not more than throo units in which the Iwmoowvcr rltudes or on the grounds apputtenan2 tb,:r o me oo(gcxPa-.dly 000aicicrcd to be
employcrs uncr the tvorycr's com}xuzation Act(GL152,ss 1(5)),application by a hotncow=far a Lccrzse or pert may cvidcnce the
leffil mater of an employer under the Worlcoes compemation Act_
I undcrttand tbzt a copy of thin rtstcmcol may be forwarded to tho Dtpwtmcai of Iodustrial Aoadrniy Ofrioo of L--LDco for tho
coverage va ification and that failure to secure coverago tender section 25A of MC3L 152 can lead to the imposition of criminal peualdcs
0001i3tiug of a fine of up to S 1,500.00 and/or ii iso�of up to one year and civil pcnaltic,in the form of a stop Work Order and a
firm o(5 100.00 a day igaitut M
For dcpu�use only
Permit Number
�3loZ
Mals*f Lot 4
Signahn-e of Liccusecfpermitfee e
7 .4
W p P
SECTION 8 CON5TRU,CTION:SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i�� � � ®�`�»»'��
License Number
Address 1 Expiration o Date
��,�,.Q � cs►�.�,�Lc.si.—_ CA�3 p 5 4 9/—!j2—(q
Signature Telephone
r ee rrt r � rrtn _ "i rac r 11111 11 �.` Not Applicable ❑
Company Name Registra ion Number
Address Expiration Da e
Telephone 411 545 i 2-A Ot`
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 affil
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 act
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
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 _
�ECTLON ". i&RIPTIONfOF PROPOSED WORK check�all a licable
3 i AN
a •n ?ir
New House ❑ Addition ❑ Replacement Windows Alteration(s),X Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Nu ��ik�Tc,u
Brief Description of Proposed Work: Cc �9A-T- � «t"i r.:G� I4j K 16' C�To- SE sy" iQ:ua4ut c
Alteration of existing bedroom Yes _ No Adding new bedroom Yes �_No
Attached Narrative❑ Renovating unfinished basement -Yes No
Plans Attached Roll ❑ - Sheet�L(5)
6 If N:e i hoA%se TaWd o . dcl':tn to::eXtgin'"t,hoMNh 3300'0 1'dte b fo"l.l:a:' " =
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 )'Pf
Frontage 1'
Setbacks Front 7
TO /f ,
Side L: 44 R: L: R:
ij��kl°QA 'Rear
Building Height CIA—
Bldg. Square Footage %
Open Space Footage / %
(Lot area minus bldg&paved Jll
parking)
#of Parking Spaces A
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 X
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:
� x
- r Northampton
EB g Department
Main Street
oom 100
AR r =i;C?Nort pton, MA 01060 f e s c a
rt
k_ _ phone 413 j587 240 Fax 413-587.1272 ear.a.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.SECTION 1 - SITE INFORMATION
This section to be comPleto-JAY off ce'
1.1 Property Address: '
t5 Gtk-&r-1e(,-A A-Vic MaP Lot ° Unit
OltZ. Zone O�erlay�Distr�ct � ��
Elm St.District CB,District '
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
Name(Print) Current Mailing Address:
.�..� Telephone
Sig re C4 l[3) 56 6
2.2 Authorized Agent:
l
Name(P Current Mailing Address:
C"a
Signature Telephone ( 4 ( '1)) 4
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building 16 560 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
2166. � Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) N iA
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5)_ !6 5- a-� Check Number
This Section For Official Use Only"
Building Permit'Number: v Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0811
APPLICANT/CONTACT PERSON BOURKE BUILDERS
ADDRESS/PHONE 77 LONG HILL RD (413)548-9214
PROPERTY LOCATION 15 GARFIELD AVE
MAP 17D PARCEL 058 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out kt C2
Fee Paid a
Typeof Construction: CONVERT 16 X 14 DECK TO 3 SEASON ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055137
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co on
LS Lcrs?__
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
GARFIELD AVE BP-2002-0811
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-058 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildini?
Category: ADDITION BUILDING PERMIT
Permit# BP-2002-0811
Project# JS-2002.1361
Est.Cost: $16785.00
Fee: $82.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOURKE BUILDERS 055137
Lot Size(sg.ft.): 11717.64 Owner: SHERMAN RICHARD K&KATHLEEN T
Zoning:URB Applicant: BOURKE BUILDERS
AT: 15 GARFI ELD AVE
Applicant Address: Phone: Insurance:
77 LONG HILL RD (413) 548-9214 Workers
Compensation
LEVERETTMA01054 ISSUED ON:3128102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 16 X 14 DECK TO 3 SEASON ROOM
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 3/28/02 0:00:00 5633 $82.50
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo