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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 -
WORICE,R'S COMPENSATION INSURANCE ATTIDAM
I, —
jicenseeJpermittec)
with a principal place of business/residence at:
(phoney#)
(strectici ty/5aie/a p)
do hereby certify, under the pains and penalties of pegury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this)ob:
(Insurance Company) (Polio Number) (Expiration Daze)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Compary/Policy Number) (Expiration Date)
r.
(Name of Contractor) (Insurance Co=any/Policy Number) (Expiration Date)
(Name of Contractor) (las r-mcti Company/Policy Nu lx--r) (Expiration Date)
(Name of Contractor) grisutance Company/Policy Numb-_r) (ExTiration Date)
(attach additiocal shoot if ncccuuy to incdudc informiIioa pertai ing to all cocasnctors)
i
am a sole proprietor and have no one working for me.
( ) I am a borne owner performing all the work myself.
NOTE:plv=be aware that while homcowvcrz who employ pc zo w&maiatcamic,oxrtn;c,-oo a rcpau work w a&Nr- rig of
not atone than throe units in wfndi the homoowncr resides or oa tho p-0 : appurtenanttberc ere oot gCr'a-2Ry oomidacd to be
employers under the wotkcx's compcsaticn Act(GL152,-s 1(5)),application by a homco Ana for a liana oc Pcrmd may cvidcace the
legal ctatu of an oazployer under tho Wort t Compemation AeL
1 undertund that a copy of this ctatcmmt may bo forwnrdod to the Dcpoct-m of Iodu ial Amdm&Offioo of In;ur.nw for tho
oovezx vaificauoc and that failure to✓==coverngo under secUoa 25A of MOL 152 can lead to the intposifioa of criminal penaltics
oomiitia of a fine of up to S 1,500.00 and/or imprisonmcrA of up to one yur and civil pcnaltia in the form of a stop Work Order and a
f=of S 100.00 a day against me-
Fa'icp�� use only
permit Number
Lot 4
ET
Signaturc of Li crmAtee
SECTION 8'-:�CQNSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: pp Not Applicable ❑
Name of License Holder ; ( �� s�l/�GG �~ (f 5 O'k
License Number
3ExpiAd ess
ration Date
Signature Telephone
..a-rn .a -�s�^ re- r
9 R"ezrStere-cfj1 me lmprovem'e""n#=Contractor. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10,,-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.GL. 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......
some �.W=1 ear emp an
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 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.
nature �`
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all apalicable)
New House ❑ Addition ❑ Replacement Windows' Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ,]�/ Other [ ]
Brief Description of Proposed Work: .,so`gZ;P
Alteration of existing bedroom Yes No Adding new bedroom Yes fp— No
Attached Narrative❑ Renovating unfinished basement Yes >, No
Plans Attached Roll ❑ - Sheet❑
sa.'If New house and r addition`to existing"=Fio`usin ;complete theaf611M k
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
SECTION 7a OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS:AGENT,.OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�a 4� r k 7' E. as Owner of the subject property
hereby authorize D�' Gr�C � to act on
my behalf, in all matters relative to work authorized by this building permit application.
to g,
Signature of Owner Date
E a 7' C. Ovs'r 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.
R.4Ew_- E' . Duxs,;.4uir
Print Name
Signature of Owner/Agent Date
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:
i
,r
Vic, -,,. --=- -:��. I y�of No S�a III Cut Per
r BLtlld' Department 'urb Cutl� v _
-
2^ `2
02 �2tMain Street ewe' I la
Room 100 Wa eUVe i va , V
Northampton, MAO 1060 T,wo sets"'of
'phone 413-58,7.1-240 Fax 413-587-1272 P o%Siie',a
i Other Sp`eclfy ��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This; ection to.be'com tetetl b office
1.1 Property Address: '- --
Map
Lotl Unit
t Zone Overlay D�str�ct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
o 6 r.4-r E. D v r r E A u 17' c,cc 6 R ook O.k_ F�Q�Ew coc mss
Name(P(PI Current Mailing Address: A/o 2-
_7_e'�'�`v� , '0_ --- ---
Telephone
-
Signature
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
com feted b ermi-plicant
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. s=ire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/inspector of Buildings Date
r�
2i. CREBR DR BP-2003.0385
GIS#: COMMONWEALTH OF MASSACHUSETTS
- CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing - . BUILDING PERMIT
Permit# BP-2003-0385
Project# JS-2003-0653
Est. Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT SKROCKI 060949
Lot Size(sq. ft.): 14984.64 Owner: DUSSEAULT ROBERT EDWARD&
Zoning: URA Applicant: ROBERT SKROCKI
AT. 21 ACREBROOK DR
Applicant Address: Phone: Insurance:
60 LINSEED RD (413) 247-9244
HATFIELDMA01088-9505 ISSUED ON:10 111102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE HOUSE & GARAGE ROOF
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 10/11/02 0:00:00 125 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo