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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 '
WORTCER'S COMPENSATION INSURANCE ATMs AVIT
(Ii censee/pecrmi flee)
with a principal place of businesslresidence at:
(phone#)
(street/ci ty/staWzi p)
do hereby certify, under the pains and penalties of peg ury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(insurance Company) (Policy 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 Coruparry/Policy Nurnbcr) (Expimtion Date)
r.
(Name of Contractor) (Insurance Compary/Policy Number) (Expiration Date)
(Name of Contractor) Gmsu ance Compauy/Policy Number) (Hxpiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additio"shcct ifn6ocnxry to include iaforrnxdcn pertaining to ell okra tors)
( ) 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 awaro that while homcowcxra who employ pe som to do rna�coustruaioa or repair work on a dwelling of
not mote than throe units is which the homoov n r=dcs or on the grounds apputtcnaat iberdo arc no(wally eoandcrcd to be
employes under the worker's.ccrrTcrts4on Act(GL152,ts l(5)�application by a homcowna for a liccux a permit may-id—the
leg:d status of an employer under the Workoet Compomation AcL
I undersumd thst a oopy of this ctatcmcnt may be foawnrdod to the Dapartmco2 of Indststrisl AC6&.&Offioo of Imrusooe for the
coverage verificalioa mad that failure to secure coverage under section 25Aof MOL 152 can lead to the imposition of criminal pcnaliies
oomut mg of a fine of UP to S 1,500.00=&Of imrxisoaz t of tip to one year and civil pcnLl ics in the form of a stop Work OrdG and a
film of S 100.00 a day against me.
ga dcpatmrtdal ttso only
Permit Number
Map# Lot#
Signature of Licenser/perrnittee
SECT,�Of�8�; ��NS��TRU��TION SERVICES, � 3
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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.
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,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and sumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State Ad Loca ni Laws d State of Massachusetts General Laws Annotated.
Homeowner Signature '``L,
S CO d SC O PROPOSEDORW '. teka ticalite� y
.. - ,;.i 53,b,1HnNfiFi.....3A__ ?St;XOAY*tlC'a g. d,Or.d•16'A N..,eP,bR.d9iUnM?C;^'s
t�ty :,3.. .:.. ..,.,. ",`:i��i>..k;;?� $'m£K,,,'�, 3,ts.a%�i✓�:,� :.... .' .._. ,'�a�` <.., f3 33f ",,, , ,,:7?»��a�', "_!'..,3:
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: 1 n eg4 1E^r,f S t�'�+� WC)CA '51 G ^e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
�I' New ouse� d 0 d�ddition tbAjd 1h lio°us�n ,`corim' 'lete t}ie#ollowin
g p g
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_ E��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
SECTION 7a .OWNERaAUTHORIZATION -'TO BE COMPLETED WHEN
OWNERS;AGENT ORCONTRACTOR=APPLIES FOR.BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
/ /� ( �rvzG(olCr ?mot 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 tier the pains and penalties of perjury.
Print Name
r„ Q
S' nature of 0 bate
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 11'q
Frontage OW /C)0
Setbacks Front
Side L:,5()_R: A5- L: R:
Rear
Building Height
Bldg.Square Footage 16 rig %
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
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: nThis sects n to=beCom'`'Ietetl 6 byoffrce
a �� t
s
j y. M p� r� ":LOt ;
t
'Al
ZOt e � s 5
.>.Flm St:District CB DIs MPRA,
SECTION 2- PROPERTY OWN ERSHIP/AUTHORIZED^AGENT
2.1 Owner of Record:.
Name(P t) Current Mailing ddress: G 7
\ i%dS�W/1
Telephone �l3
Signature T
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (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) Check Number
This Sectibn�For Official Use Only,
Bullding Permit Number Date Issued:_
3 r�
j
Signature �.. .
., k�
BUilmg Cofitn�ssioper/Inspector ofBuildings. , Die ,
164.1`L YHILLAD BP 2002 0455
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Black:34 r 008 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Woodstove BUILDING PERMIT
Permit# BP-2002-0455
Project# JS-2002-0685
Est. Cost:
Fee: $24.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 10018.80 Owner: WENDOLOWSKI MARK A&ALICIA
zoning:iR Applicant: WENDOLOWSKI MARK A & ALICIA
AT. 164 TURKEY HILL RD
Applicant Address: Phone: Insurance:
P O BOX 965 (413) 585-5874 ()
EASTHAM PTON MA01027 ISSUED ON:10125101 0:00:00
TO PERFORM THE FOLLOWING WORK:INSPECT EXISTING WOODSTOVE
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 10/25/01 0:00:00 1676 $24.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo
164 TURKEY HILL RD BP-2002-.0455
GIS#:
COMMONWEALTH OF MASSACHUSETTS
Map:Block:34-008 CITY OF NORTHAMPTON
Lot:-001
Permit Building
CategorX:waodstove
BUILDING PERMIT
Permit# BP-2002-0455
Project# JS-2002-0685
Est. Cost:
Fee: $24.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use GromR:
LotSize(sq.$.): 10018.80 Owner: WENDOLDWSKI MARK A&ALICIA
Zoning:RR Applicant: WENDOLOWSKI MARK A & ALICIA
AT.- 164 TURKEY HILL RD
Ap„Plicant Address: Phone: Insurance:
P O BOX 965 (413) 585-5874 O
EASTHAMPTONMA01027 ISSUED ON:10/25/010:00:00
TO PERFORM THE FOLLOWING WORK:INSPECT EXISTING WOODSTOVE
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: FireMartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:O
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate Of Occu an i nature,
Fee Type Receipt No: Date Paid: Check No: Amount:
Building 10/25/010:00:00 1676 $24.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-11272
Building Commissioner-Anthony Patillo