17C-142 (2) r 4
4.t1tAMPTO
.�O °
A fl Grxt� of
6 j3�+taaxc3lasctta'
m DEPARTMENT OF BUII.Dr NG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1,
with a principal place of business/residence at:
(phone#)
(str cWcity/statr/ap)
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 following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Number) (Hxpimbon Date)
(Name of Contra ctor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shcet ifntcc ry to indudo informs-don pertaining to all occ&ador3)
O I am a sole proprietor and have no one worldng for me.
�I am a home owner performing all the work myself.
NOTE:please be aware that wtnlo homeoAven who ernplay pcaocs to do m urtcaaa r,=n:T=-or repair work on a dwelling of
not morn than thmo units in which the lwmoowncr midcs or oa the grounds appurtenant th,,c arc nM grncrally comickrcd to be
employers under the worker's ompens4cu Ad(GL152,n 1(5)),application by a homcow=for a license or p�md may cvidcnoc the
legal s tatua of an omployer under rho Woukcea Compoosation Ace.
I undcrtund that a copy of this ctntcuwcd may be forwarded to tho Dcpartmcr t of Industrial AD i&-&Offioa of Iu vr*nce for tho
coverage verification and that failure to sxttre coverngo under Section 25A of MOL 152 can lid to the imposi -of cr tnin.l pcnall:es
ootnisti of a fine of up to S1.500.00 and/or imprisonment of up to one yt err and civil pcnaltics in the form of a Stop Work Ord--and a
firm of S 100.00 Idly against Me-
For dgnat'O� tsao aaly
permit Number
Mao Lot#
of Licrosce-Rermittee
� '
SE -
CTION 8-,�CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
R to m r vemen n r' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
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.
omeowner Signature ��
SECTIONS DESCRIPTION OF PROPOSED WORK(checkall apahcable)
r n �+*d»•,>.e3W�M, =:*-re*v zz ok�.lb-m...k'.A.a+nxSx�5 i .d.i- MW 9 .Y .•,
w ,l,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 11 1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: k�icj✓x {
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet❑
6av ff NeMb se-a tl r&tt idition`to eki-§ting:hou�sing,wco`rriplete fhe foll"owing:
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
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
Print Name
,wz — 0
Signature f Owner/ gent 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 r/ 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:
w
o '
' r
orthampton
Bui i Department
�1 2 ain Street
5 202
o m 100
mpt n, MA 01060 e
aE pF�ttogmA101�TUl 7-12 0 Fax 413.587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section fftce
1.1 Property Address:
NIaP s ° ;.. Lot,
Zorie - =�Ov"ertay�,Distrtct�� � �`
Elm`St. District' °`CB D�strrct�
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: f
tPXi/.,4 1142 GZ.C��E.WSlC �`,9 JIY
Name(Mint) Current Mailing Address:
Telephone
Signatur 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
completed by ermit applicant
1. Building ® p (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 0
.This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
' r
. hT=
BP-2003-0261
GIS#: COMMONWEALTH OF MASSACHUSETTS
'& CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0261
Project# JS-2003-0459
Est. Cost: $600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa.ft.): 15812.28 Owner: MOCZULEWSKI PHILIP J&
Zoning:URB Applicant: MOCZULEWSKI PHILIP J &
AT. 126 HIGH ST
Applicant Address: Phone: Insurance:
126 HIGH ST (413) 586-7773-0
FLORENCEMA01062 ISSUED ON:9113102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH WINDOWS & SIDING
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 9/13/02 0:00:00 1480 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo