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$ 6 �tssacflttsctta'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORICER'S COMTENSATION INSURANCE ATITIDAVIT
(licensec/permittee)
with a principal place of business/residence at:
(phone#)
(streeUci ty/state/a p)
do hereby certify, under the pains and penalties of penury, 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 foiioVving worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expirmion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expirtion Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(nuAdi additloczul sheet ifrtccs xy to include informstioa pertaining to ell o Lxadors)
am a sole proprietor and have no one working for me.
I am a home owner performing all the work myself.
NOTE:please be await that whilc hcmcowvcn who crnploy parom to do a.:,,jcnjnct C=r tr,;oioa Cr repair work on a dwelling of
not more than three units in Wfi ch the homcow ncr raider or oa tht grounds appurtenaat thact.o art rx�,(gully coasidacd to be
employtsa under the wo>kces cecnpcM4ca Act(GL152,::X1(5)),application by a homcow=for a license a permit may evidence the
]tgal ctarua of an employoc under the Woriceet Compmufion Act_
I undcnttnd that a copy of thin ciatcmc it may bo fm-wnrded to tho Dcpartnsmi of 1.&,3t ial Amid-&OfSoo of inavc*nco for tba
coverage vaifscalioa and that failure to secure oovaago under scciioa 25A of MOL 152 can lcad to the imposi -of criminal pcmaidcs
oomiat=g of a fine'of up to S 1,5 .00 and/or impr6oanrmL of up too=year and civil penalties in the form of a Stop Work Ordc and a
fuze of:3 I00.00,a day tpinst
For dcPxW, t-1 use only
/ Permit Number
Lot#
Si of LtccuseeRermittee te
SECTION 8.,CONSTRUCTION SERVICES
8.1 Licensed Construction S rvi r: Not Applicable ❑
Name of License Holder
License Num4er
Address Expiration Date
SignaTo / Telephone
r .� - ,. • n_ f�ly� Not Applicable ❑
Fibmiim t vemen n rac r . ..u �. �
Company Na j Registration Number
1 /
Address Expirati n Date
Telephone k-�,Z
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......
g' a`\ 9lMa: aro� s* R`by'y�.v! ` M �''
H,ome�OwnerlExemption.
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.
Homeowner Signature —
SECTION 5-DESCRIPTION OF:PROPOSED"WORK(check al!'applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding[ ] Other [ ]
Brief Description of Proposed Work: dens r� cis _
Alteration of existing bedroom Yes No Adding new bedroom Yes �:No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
� ao gd�rc es g ; carriplete.thefollowing
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. T ype 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
i, — LirL141L�
J,-J k6--tJ as Owner of the subject property
hereby authorize � .���S to act on
my b half, in all matters relati e to w rk aut orized b this building permit application.
<v 8 0
Sign ure of Owner 117 Date
I, 0 as Owner/Authorized Agent
hereby declare that the sta ements 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.
Pri me 1A '1 [0 a.,
re o
f 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:�?1> R: t )
Rear \d—c '
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:
rq
C. Do any signs exist on the property? YES NO L/
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:
{
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•
t f Northampton S P r
i ng Department
1 2 Main Street
JUL ��02 Se s° to
oom 100
ha pton, MA 01060 T else ' c a:
DEPT Of BOI ' , E (8-5 240 Fax 413-587-1272 �° /Site P€an;;
Qthe Specify ..-.�a��
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION;,1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
S t� Map Lot zJn�#
M Zone Overlay Distrtct�
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N e(Print) Current Maiiing Address: t
clez ✓ — Telephone
S' iature l
.2 Authorized A e
Name (';ri t) Current Mailing Address:
Signa re Telephone y
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) (} (3 : C t� Check Number !�
This Section For Official Use Only
Building Permit Number: Ftelssued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0052
APPLICANT/CONTACT PERSON John Punska
ADDRESS/PHONE 5 Dimock St (413)584-5533
PROPERTY LOCATION 989 BURTS PIT RD
MAP 36 PARCEL 098 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REPLACE CONCRETE STEPS W/5 X 9 DECK W/STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building_Plans Included•
Owner/Statement or License 039852
3 sets of Plans/Plot Plan
THF LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NJ ATION PRESENTED:
ved 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 C ssion
Lod Z
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.
:� ITRD BP-2003-0052
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0052
Project# JS-2003-0132
Est.Cost: $1800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Punska 039852
Lot Size(sq. ft.): 21300.84 Owner: JOHNDROW JEANNE S
Zoning:URA Applicant: John P u n s ka
AT: 989 BURTS PIT RD
Applicant Address: Phone: Insurance:
5 Dimock St (413) 584-5533
LEEDSMA01053 ISSUED ON.7125102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE CONCRETE STEPS W/5 X 9 DECK
W/STAIRS
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 7/25/02 0:00:00 MO $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo