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I I All dimensions size designations given are +]r1 ''J( ya "This is an original design and most not be KOLODZIE....kit Designed: 3/23.
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DEPARTMENT OF BUILDING INSPECTIONS 4 _
• . 212 Main Street • Municipal Building` l �
Northampton, Mass. 01060 �
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, j ,� D k- v�T l ,0/1` ,
(license&permittee)
with a principal place of business/residence at:
• (phone #)
(streei/city /statthip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
• (Insurance Company) (Polio 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) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet ifnecesaary to include information pertaining to all contractors)
(1I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself
•
NOTE: please be aware that while homeowners who employ persons to do maiutManf; construction or repair work on a dwelling of
not more than three units in which the homeowner resides or on the grounds appurtenant thereto arc not generally ooaridacd to be
employers under the worker's csccopecastion Act (GL152,s3 l (5)), application by a homeowner for a license cc permit may evidence the
legal statue of an employer under the Wockees Compensation Act
I understand that a copy of this rtatcmad may be forwarded to the Dope rtmcnt of Industrial Accidents' Officio of Irr urwnoa for the
coverage verification and that failure to secure coverage under section 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine of up to $1, 500.00 and/or of up to one year and civil penalties in the form of a Stop Work Order and a '
fine of S100.00 a day against me.
// For departmental use only
!�� P crinit Number
�� � �,� Sure Licensee JPermittee
Lot 4 :.
> te
kiimo w ,: �.,zti,
8.1 Licensed Construction Supervisor: [ Not Applicable ❑
Name of License Holder : ( (qV [ it) rvtiv 1 PEA-- DC . g$01 C.
Laug_6,1.. q / L icense Number
�? , /V02T414/ 11A-c 3//o o 1— Addr s i / Expirati6n Date
Tz -71 leg
Signature Telephone
I,
411; ^ - ,. w trAi1R ".isiii' arils '-IR ? i ® Applicable .....''.. ,...�� NotA ❑
1 3 9
Company Name Registration Number
OAuui f - T(rlG OG� S ? l o G Z
Address Expir ion pate
32- LJLL /Vot, ?, qtP Telephone 5 G- 1G J�
SECTIQN '1D OFD, ERS�C P,E (M G it. °yC X52, §2C( 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 o 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) 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, von 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
8 x � 7 ^` E sC � r , .., -� .. � � °� � t a � Sb tg �� ��'�.§. �,. �
New House ❑ Addition ❑ Replacement Windows Alteration(s) l Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ DemolitionE' New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: b &T t LTC tAv Alt 5 fiArco Ck (A/CI - ALC. A V0 CA6(4/ (E fS
Alteration of existing bedroom Yes IV Adding new bedroom Yes �. No
Attached Narrative 0 'Renovating unfinished basement Yes
Plans Attached Roll Roll 0 • Sheet 0 y Y
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 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
� 9zes � ,. a ffC E
�
1
I, `' Ao , as Owner of the subject property
hereby authorize G r r/ ori'kP to act on
my beh I in all ma ers rela ive to work authorized by this building permit application. oo
Signature of ner ' Date
I , Ono 1 p f V < ("� .� r (�fiz4- , 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.
iJQ utn A)• IL-°/1-114/L.
Print Name \471 1/ a (
Date
Signature of Owner/Age
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 v'
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:
:S• , � .ti ,.
k
,
City of Northampton - A , -. A,,,,,,,,,...,.,
Building Department �__�_
212 Main Street
Room 100
� ..: � Fr � r
Northampton, MA 01060 ; <_. � •_:. , =n, o�
phone 413 - 587 -1240 Fax 413.587 -1272 ?t : '� - -, ' r,
.Itr „X,Yr , -
L APPLICATION TO CONSTRUCT, ALTER, REPAI G; Nc A dj DDMLI L • `:+ ; OR TWO FAMILY DWELLING
MAY — 8 2001
I"'1St- . - r s,. IH , .. o nl
DE , ' f m `etio t' a o
c rmpf • 11,7'7,:i. 7 8
1.1 Property Address: N. , ' I ,
p kiticiksi0( Ofe. ii.kii4-zi'?'6r:::17;:iikr"7:*--1.(,?::';',.P2,7:rlitliii1;15?:K.:.g•i'l"°?;:#:,F;;:i-:;..! ,..:4';.:',',,:,°,:'1'1-.;',,g'.::'t',:iii;;5:',:',
E 1 , P tOP RTY O WNERSHIP /AUTHORIZED AG
2.1 Owner of Record: i-
��, \\ A '(�,,GAZ., c' f � R ;sec ;ode r •
.
( Curr MailinPd ,
Name Pr',oi / �J � ��� � 0 � � q�
Telephone
Signature 11 /`'
2.2 Authorized Agent:
3 )- Z-A4.1 'C '-'-- / • /(1c,„'it - 17/44/1,7 ) MA,
t�t) Current Mailing Address:
Name
Signature I/ Telephone
%, e 3 i U ! N _ Ti ®
Item Estimated Cost (Dollars) to be O fficial Use Only
completed by permit applicant t ' ',":0b
1. Building (a x tang Perm ee � �
2. Electrical 4 i 4o . U i e t '' ta�� �f . f � �� e
G , ..: fit: `t uctlon } featrif(6) , L _� z :..'': ,. 7'
3. Plumbing ' BitildItigP.PermitfFe , I 1,'
4. Mechanical (HVAC)
5. Fire Protection
f �
6 Total (1 + 2 + 3 + 4 + 5) -�• 1 7 �� fJ�'i ����'�,��er� ��'�"� � �� � �� ��) � � 4.;:gg!!4
z; u '� $ fir' k ' t :, "4 a ' r-, a *” ' ;C ' a s x a
,
..>„'#� ,,sr '. , ,,x. ;t6A '� xim",x rn
I. Ol e '.sw � i
t, r r 74«.;...w, i I '� G✓ , ^
' ' a . -' i1 n s#e> eflltispector o Builiiirtgs ,, , . pat ,,
82 RIVERSIDE DR BP -2001 -0902
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D - 041 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2001 -0902
Project # JS- 2001 -1629
Est. Cost: $14744.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: 5B Contractor: License:
Use Group: David Fortier 008026
Lot Size(sq. ft.): 7492.32 Owner: KOLODZIEJ JAMES S & SALLY ANN
Zoning: URB Applicant: KOLODZIEJ JAMES S & SALLY ANN
AT: 82 RIVERSIDE DR
Applicant Address: Phone: Insurance:
82 RIVERSIDE DR
FLORENCEMA01 062 ISSUED ON :5/10/01 0 :00 :00
TO PERFORM THE FOLLOWING WORK: DEMO KITCHEN, RESHEETROCK , INSTALL
NEW CABINETS
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 NORTHANMP"TON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature:
Fee Type: Receipt No: Date Paid: Check No: /Amount:
Building 5/10/01 0:00:00 3621 $65.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo