25C-047 r
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street r Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
with a principal place of business/reside ce at:
hone#
/ (p )
( city/ ap)
do hereby certify, under the pains and penalties of perjury, that
O I am an employer providing the following worker's compensation coverage for my
employees wor c ng on this job:
a=u-ance Compaay) (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 Company/Poky Number) (Expiration Date)
r.
(Name of Contractor) Gmsurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (msurane–c Comp ny/Policy Numhe-r) (FA-piration Date)
(Name of Contractor) (Insutancc Company/Policy Number) (Expiration Date)
(attach additioail s-S c if neeczzzry to ioc]ude inforuuticc pertaining to all ecerirnctors)
i
I am a sole proprietor and have no one worldng for me.
( ) I am a home owner performing all the work myself.
NOTE:please Ue aware that whilo homcovvnm who cmplay pa.om w do m�i com ntction or repair wvric on a dwelling of
not more than thrcc units in which the homoowncr rtaidc3 or oa the grounds apurtenant tha cto arc not&,ju lly oowidcrcd to be
employers under the work&,ccarpcssatioa Act(GL152,a 10)),appdca6on by a homcowncr for a bears=cc per i may cvid—the
legal et atus of an amp loyev under tha Wor$or's Compmlation Art
I understand that a copy of this efatement may bo forwnrded to tbo Dcpartr c of lodusirial A..6&n&OfSoc of Iratraoco for the
coverage verification and UW failure to Sxnue covetago under section 25A of MGL 152 can lead to the imposition of criminal penalties
oomtsting of a fine of up to S1,500.00 and/or imprisonnxaL of up to one year and civil penrttics is the form of a stop Work OtdG and a
fins of S 100.00 a day L&&inA Me--
Foe dgJUhx-onl tsao onfy
permit Number
Z ��2L�Z tvfap l Lot 4
of LiccnseelPermittee e
Y �
SEGTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not�Appliccaab�le 0 p'(�
Name of License Holder : i15 Aagt: l �/ L'� �Q 7
License Number
DI /-. ad
A Expirat on Date
S-ilTrature Telephone
R re r. eeme`n n ra°. r MI fi � '` ' Not Applicable ❑
Company Name Registrati n Number
�r �/� : %//OZmot
Address Expiration Oate
Telephone- S-1;,6-
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....... LV 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 Dr 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
V, PROPOSED WORK check all:aaalicable)
SECTIONS DESCRIPT I ON O =(
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors J�'
Accessory Bldg. ❑ Demolition❑ New Signs/[ ]] Decks [ ] / Siding[ ] �O1ther[ ]
Brief Description of Proposed Work: 2r1�/c� P i7f G✓+"✓J06G'�. XLew k�f t (-bi%4 Go1/�5
Alteration of existing bedroom Yes f No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
"IfNewhouse,andor'atltlition"to existinghousing comp'etetfie�fol"Iowan :
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;OWNEWAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS'AGENt OR CONTRACTOR APPLIES FOR.BUILDING PERMIT'
/
Kwr 2--` as Owner of the subject property
hereby authorize £ I'' to act on
my behalf, in all m ter rel five o work authorized by thi ilding permit application.
Signa ure of Owner Date
as Owner/Authorized Agent
hereby decla that the statements an" information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed der the pai s and penalties f p71 /Pq
Print Na
Z z��-
Signat ner/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 i�l. 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:
r-�" t; 1:�City of Northampton
°BtAld,ing Department ra.ff
212 Main Street
DEC �rRoom 100.
F Northampton, MA 01060
F y.
i ;;� sfe3•�587 1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sections#o be�completed by office
1.1 Property Address: � �
EIm;St District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: iq
i Any�/f
Na P int) Current Address:
..y►�. Telephone
Signature
2.2 uthorized Agent:
Na (Pri Current Mailing Addr ss:
S
e Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
feted b ermit a licant
1. Building
,com
(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 D
This Section For Official Use Only"
Building Permit Number W.4 +V7 Date Issued:
Signature:
Building Commissionerllnspector of Buildings Date,
File#BP-2003-0577
APPLICANT/CONTACT PERSON C&T Construction
ADDRESS/PHONE 15 Fairway Drive (413)586-4965
PROPERTY LOCATION 218 NORTH ST
MAP 25C PARCEL 047 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL REPLACEMENT WINDOWS,KITCHEN CABINETS, SHEETROCK WALLS
&TRIM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 062884
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 C .ssion
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.
BP-2003.0577
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003-0577
Project# JS-2003-0950
Est. Cost: $12500.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: C & T Construction 062884
Lot Size(ssq. ft.): 5706.36 Owner: KIREJCZYK STEVEN G&PAUL D
Zoning.URB Applicant: C & T Construction
AT. 218 NORTH ST
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON:12116102 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS, KITCHEN
CABINETS, SHEETROCK WALLS & TRIM
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 12/16/02 0:00:00 3048 $60.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo