32A-247 (3) R E Gift of �R� tllant}�tnit
DEPARTMENT OF BUILDING INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
WORRER'S COMI')✓NSA'MN INSURANCE AFFIDAVIT
(li cctius/perrni ttcc)
%Vith a principal place of business/residence at:
(stT�t/city/staicla p)
clo hereby certify, under the pains and penalties of perjury, .h i
( ) I am an employer providing the following Worker's compens.von cove;a^e for Inv
employees wor..6Ing on this job
(Lusur2nc-c CoiDr,2nv) - -- (Polio:N.u_-nLr_r) ---- (E�,pir Lion Dare)
( ) I am a sole propretor, general conn-acwr or homeowner (cLrcie one) and !Nave hired
the contractors listed below who have the foBoWVing Worker's coinnensation policies:
(Name of Conr::Icrorl (Inter-anc; Coinpany[Pouc; N=k-,)
(Name of Con[Taclor) -- —Osissranc;. Company/Polio• vuc -r) (Lspir:tioa Date)
(Name of Contractor) Gnsuranc; Company/PoLcy N,unber) (Bpim[ioo Daie)
(Name of Contracior) (Insurance Company/Policy Number) (ExpimDoo Date)
(etiach addr'uoaal rxd if n<ccni^:w ax!ud.uzfo�v-utioo pcztninins to nll wa_rn�4:�)
( ) I am a sole propnetor and have no one working for me.
( ) I am a home owner perfort�ing all the work myself.
NOTE:plc= Lx zwa t Q,,u'„]c bccnccA�n wbo employ pazotu w do a�� urn G oa c rcaau uori;o d%—U--,,of
not mocc thVn throe L--Lm'j is u',ncL tlx the voun'dd a thccw zit c'A Gcnczlly o rr:d cd n b
catploym under dlrµ�06: ar pcz--lioa t%f--(GL15L-31(5) nfVUcafloo by e homcOavcr far t 6anr_a P�v [ y—&—x h
hind'Lt of nn aazrployor under dw Workoe[comp--Ls Act
^. I understand d'xt a copy of this rx Lc-urn[m.y bo forv..nrded to tba DcQartmcut of l.,ri_c.i d Aco&-&OfLoo of Irl—for tlx
oovmiSc vcrificstioo end that f_11—to u0 r covcresc under soctmoa 25A of MGL 152 can Icsd W the itnposdioa of airmail pcailtics
ooali5ing of a fine of up to S 1500.00-rtdfor u of up to 0�year end a-,il F,sMfLa in dx fcxtn of a Stop Wort Ordc end e
fim 0C S 100.00.day tgAura ny-
For only
Permit Number
--- - -- -- -- Mmps1 - - ---Lot -----
SignalurL of 1,iccnscrJYc rill iticc
.
o* ,
4�6&CTION 8 CONSTRUCTION SERVICES
-.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
iA
Not Applicable 0
Company �Lame Registration Number
Address Expiration Date
Zl��4--,Telephone Ito 0
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.
TWO twu
The current exemption for^booeovnem^was extended tuinclude one(1) or two(2)§uuUieo
and»o allow such homeowner to engage ao individual for hire who does not possess ulicense,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 oo which he/she resides or intends to reside,oo which there
is,oriu intended tohu,uoucortwofanib/dwuUbug'uttuobedurdetuubudxUouUuromaoce000ry0oouuhuyuuud/orbom
atrouuoeo. .
Such^'bomcovnnor'shall submit to the Building OffiuiaLouu form acceptable m the Building Official,
responsible for all such work performed under the buildini!permit.
As acting Construction Superviso your presence on the job site will be required from time to time,during and upon
completion of the work for which this permit ixissued.
Also ho advised that with reference to Chapter l52(Wodcera' Compensation) and Chapter lj3 (Liahilhyo[Empluyernto
Employees for injuries not resulting in Death)ofthe Massachusetts General Laws Annotated,you may be liable foopcx000(x)
you hire to perform work for you under this permit.
The undersigned'hoozeunmer`uertificxunduouumeorcopouyihi|hy for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State o[Massachusetts General Laws Annotated.
Homeowner Signature
,
;Oft-CTION 5- DES(;Rlf!TION OF PROPOSED WORK(check all applig;ablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
$ ...
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
Energy Conservation Compliance. Mascheck Energy Compliance form attached?
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
I 'S�/{-��f�—l� 7 (t� l<-� as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative t authorized by this building permit application.
0 C.)
Signa ure of Owner ', Date
I, 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.
,ned under the pains and penalties gf rjury.
( .Ac- le
Print Name art
A I u � r �
Signature of Owner/Age Date C7 "'
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
low 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:
fo ,
ity rthampton
* '
Id ,bepartment Zs
1 M 'n Street
Ctl
0 100
Of BUILD►t
pEPi �,�.►` �, � MA 01060
►' - ' 7.1240 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:
This section t :completedce)
A q 1=A-l 2 S Map Lut' CJnit
Ala la-7—bl tk 'b 1--a done 7uerl i (strict
Elm$t.District CB District '
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Pt-6 Al
S r A-M 1.r::-`Y v 4y 1= P0 6 6)( 1--3
a el Print) Current Mailing Address:
" Telephone �$ y - Y
Signature
2.2 Authorized A nt:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building �c �5 (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6 I
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2+ 3 +4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Comm iss loner/Inspector of Buildings Date
39 FAIR ST BP-2001-0252
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-247 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2001-0252
Project# JS-2001-0428
Est.Cost:$4400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq.ft,): 30230.64 Owner., ZEWSKI STANLEY VICTOR&VELIA
Zoning:U Applicant: Larry Paquette
AT. 39 FAIR ST
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:9112100 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/12/00 0:00:00 2596 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo