17C-142 (3) a.
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$ 6 �aaaari(asctts
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(I i cen serJpermi tLee)
with a principal place of business/residence at:
(phone#)
(stre,Wcity/stalr/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/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atlach additiooil sheet if noocaary to inclwic inforn Ltion pertaining to all ooatradon)
( ) I am a sole proprietor and have no one"working for me.
am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowocrs who employ pcnow to do,n.;.tca 1c, cmen=on or rgair work on a dwelling of
not morn than three units in winch the bomeowncr resides or on the grounds appurtenant thereto arc not gena<nlly oo=datd to be
employers under the worker's coavcasatim Act(GL152,,=1(5))�application by a homeowner for a lictwo or perm may evidence the
legal status of an amployet under the Workoet con ma3&tion Act
I underhand that a copy of this rwcmcat may be fm wnvdod to tho Dcportmcat of In&L Uid AD6d4e Offioo of Ir- won for the
coverage vexifladioa and that failure to sec=coverage undcr section 25A of MOL 152 can lead to the imposi oa of criminal pcna -
00austiag of a fax of up to 51,500.00 andlor of up to one year and civil peniNC3 in the form of a stop Work Ordtr and a
fmo of 5100.00 a day agaiml ma
For 1 use only
Permit Number
I&p* Lot#
��� Si of Liccnsce/Pernuttee e
' � R
r
SEC 8 �CONS7�RUC7IQN°SERVICS
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
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...... ❑
om .'Own , empt><
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.
*M owner Signature /�/
x k m a �
S FTI,O, D PRO �OzSEQNORK clifecal' alicalile
3
fld&^wi dk 2: I *3i
Tr` .',
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessor B ❑ Demolition❑ New Signs [ J Decks [ ] Siding[ J Other [ ]
Brief Description of Propos d Work: je���.� .��so db �.t i� - OAZ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
N h e�ando adtlitionto..ezist�ng.lions'incornpl'eteth'efol`Ioini :
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 7� OWNER AUTHORIZATION -'TO BE COMPLETED' WHEN
QVIINERSxACaENT OR CONTRAGTOR;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
ig�dwner/Age Date
F
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 -X
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 ,
Northampton
Q C� g Department
1 Main Street
j OCT 2 6 2-00I No 100
No pton, MA 01060
ph 87 240 Fax 413-587.1272 ,t
DEPT OF BUILDING INSPECTIONS
NORTHAMPTON, A 01060 ;Ot e Spec
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section�tabe compteteilEti offrce
1.1 Property Address: " .... b<
�LO.pev G t/ Zone
ma
0 FIE'
Aug
E�Im SVDistrict
F .
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AG ENT
2.1 Owner of Record:
-j66/,00 C L✓!t[✓S4 /a�4' �e'� �S'� �Lu,t?t�, C{. O/O
Name(P nt) Current Mailing f(ddress:
Telephone
Signature
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 b ermit applicant
Building u (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
This iSectiAn For Official Use O.hl
Butlding:Permtt'Num6er Date Issued
uB,Id Cm r/nsp" o 09 s,
A ST BP-2002-0459
COMMONWEALTH OF MASSACHUSETTS
),ck: 17C 142 CITY OF NORTHAMPTON
)1
Building
;ory:roofing BUILDING PERMIT
lit# BP-2002-0459
ect# JS-2002-0693
Cost: $300.00
$25.00 PERMISSION IS HEREBY GRANTED TO:
)nst. Class: Contractor: License:
se Group:
of Size(sq. ft.): 15812.28 Owner: MOCZULEWSKI PHILIP J &
Zoning: URB A-plicant: MOCZULEWSKI PHILIP J &
AT. 128 HIGH ST
Applicant Address: Phone: Insurance:
126 HIGH ST (413) 586-7773 O
FLORENCEMA01062 ISSUED ON.10/26/01 0:00:00
TO PERFORM THE FOLLOWING WORK ST R I P & S H I N G L E BA R N ROO F
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 Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/26/010:00:00 1385 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo