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17A-300 (4) O Oef WV Vs Pe 0( di,�)twoit 6�N I'A 6WIC eL -FL IVA; The Commonwealth of Massachusetts Department of Industrial Accidents i -- _- Office 011nyestiffaff s 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit name: location: °�.� 1,4 l L c oE-c,, city �� ``' /- C M A- phone# Lf(3 F] I am a homeowner perforating all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. company name address: city: t l Z f7 t'� C� 1 6 D insurance ca C! �, �a?'l ipi�F� Y45 `i? ,. olic # G ` 5 c,.a� f�c�:E f-1 I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: - address: city: phone#. ` insurance co. Policy.# <. company name: address: city: _phone#• insurance co policy# Failure to secure coverage as required under Section 25A of MGL 152=cad to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. 1 do hereby certi y under the pains andpenalties ofperjury that Cite information provided above is true and correct. Signature Date Print name c: }Yv ' r , „s�(c I/ Phone# official use only do not write in this area to be completed by city or town official city or town: permit/license# nBuilding Department ' []Licensing Board O check if immediate response is required p Selectmen's Office Er pHealth Department -', contact person: phone#; rl0ther �aV (revised 7/95 PJA) SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable £ Name of License Holder: �°t'�`t 1' �" I L'�t i +-r`�/� —��� 7- f E / License Number Lt)v 61 b ,el D 6 6" �.,i 1'� F �z ;� /Y l4 zA y Address rV i o Expiration Date Signatu Telephone 9.Reg—i-s�tered Home lmarovement Coritractor Not Applicable £ ( ;�t Company Name Registration Number ©Gn 133 Address Expiration Date Telephone Z (S 3 fly' o 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 Attach d Yes... ... £ No...... £ 11.--- Home Qv ni r,Exemption' 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 all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding [O] Other[p] Brief Description of Proposed Work: •1" Yv tS'o 1cvZ f t>T/ Alteration of existing bedroom Yes No Adding new bedroom Yes "-�No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll She ._ sa, if New house antl,or additionao existing«i ousing, complete the"following: a. Use of building :One Family >4 Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? y� d. Proposed Square footage of new construction. 4-5,0 f5a r7- Dimensions e. Number of stories? hll'YS 1.5- ----f f. Method of heating? 6>F? '--�+ s'n— Fireplaces or Woodstoves G' Number of each 4' g. Energy Conservation Compliance. Masscheck 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 I,AovG � a d ) V as Owner of the subject property hereby authorize -� CDt`,.l 14, `:-[ to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, ,� x't k fi. "�— •�—'`r + rJ hl�.� as Own /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m edge and belief. Signed under the pains and penalties of perjury. Print Name Signature of;0 ner/Agent Date kJ . , - , Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning TIiis column to be filled in by Building Department Lot Size Frontage Rear Building Height Bldg,Square Footage % Open Space Footage % (Lot area minus bldg&payed #of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? ��/«°� �-^�/� NO ��/ DONTKNOVY YES IF YES, dateissued1 / IF YES: Was the permit recorded at the Registry ofDeeds? � ' NO ~\ �|uU� xnuW 0 YES IF YES: enter Book Page and/or Oocument# B. Does the site contain a brook, body of water or wetlands? NO ` DONT KNOW 0 YES - IF YES, has permit been urneed to be obtained from the Conservation Commission? Needs tobeobtained 0 Obtained �~\ Date Issued: C. Du any signs exist on the property? YES �~��/ NO IF YES, describe size, type and location: D. Are there any proposed changes tonr additions of signs intended for the pmpe�y? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excavation,or filling)over 1 acre or\oit part ofu common plan ' that will disturb over 1 acre? YES NO _ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ -' h M�- Deparfinentuse only City of Northampton Status of Permit r k V 2 t�i�i`� �` Building Department curb cutlDriyewa LFEB y Perm�f rt t 212 Main Street !Se wer/S "PP ticAv al. rabthty &Gas tnspe� Room 100 WaterMtel[Rvailabdtty ctric,Plumb'ng n G 01060 rthampton, MA 01060 Twa Sets of Structural Hans ; Northampto . phone 413-587-1240 Fax 413-587-1272 Plotisitie Plans Other Specify' - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - 1.1 Property Address: This section 16.!b e;compI ted by gffice Map Lot U ft Zone = Overlay District { Elm St Distri ct C8 District -1 1" SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: rs a 13s' Name P 't Current Mailing Address: /f Telephone 5 ature 2.2 Authorized Agent: / .S tr��yJ f� 2 i �i �..r sr c t �C t,{.� e�o b �1.t.7 6 c= c/� /•�i f`/t-��/'-1t= Name(Print) Current Mailing Address: Z—t cl SignKure 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 S 5T 2. Electrical v C,c, _ (b) Estimated Total Cost of Construction from 6 3. Plumbing 3 c>o e, - Building Permit Fee 4. Mechanical(HVAC) `- 5. Fire Protection '3�UlJ 6. Total=0 +2+3+4+5) v z)c> '' Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0774 APPLICANT/CONTACT PERSON JOHN ZIEMINSKI ADDRESS/PHONE 10 WOODRIDGE CIRC HATFIELD01038(413)247-9014 PROPERTY LOCATION 135 HILLCREST DR MAP 17A PARCEL 300 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 0777 r6r Z-0 Fee Paid Typeof Construction: FINISH BASEMENT(BATHROOM PLAYROOM OFFICE LAUNDRY RM) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 017889 3 sets of Plans/Plot Plan THE FOL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN O 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 Commission 'Permit DPW Storm Water Management t e ay nature of uildmg 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. 135 HILLCREST DR BP-2015-0774 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-300 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0774 Project# JS-2015-001513 Est. Cost: $25000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq_ft.): 21867.12 Owner: CARDOSO ANDRE&KATE Zoning:URA(100) Applicant: JOHN ZIEMINSKI AT: 135 HILLCREST DR Applicant Address: Phone: Insurance: 10 WOODRIDGE CIRC (413)247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON:21512015 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT (BATHROOM,PLAYROOM,OFFICE,LAUNDRY RM) 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 Occupangy Occupancy Signature: FeeType• Date Paid: Amount: Building 2/5/2015 0:00:00 $150.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner