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17C-097 4 O�livlrpT0 Crii of �r� tllbillt�Ji01t _ -_ � ~ E �tiz�arhnt:rtta' _ o DEPARTMENT OP BUILDr\IG INSPECTIo?"s — 212 Main Strect ' Municipal Building Northampton, Mass. 01060 WORKER'S CO 1'Q'EN S A TT O N LN S U-I A CE A I-'FM A VI-J' (Ii ccvsccJpermi tttx) �Vith a principal place of business/residence at: s'7': �Zu�L /yl�-(phone' ya3y �� (sa�c/caty/sza ebp tsiG'11' do hereby certify, under Lh.e paint and penalties of perjury., hat (✓I'I am an employer providing the followint workcr's comoens-nbon cove age for etuployces wor-�Jng on t.iiis job: � 6 y (Instr Corr ) (Polio: Nu nir_r) (r:-pirz on D2i--) O I am a sole proprietor, general contractor or homeowner (ci cie one) aid Lave hired the coop actors listed below cgbo have the following workers cocDtnszdon policies: (Nam-, 0-, Co=ci0') (IRRf3rioc Coino33))•fPGUCf NIUIIt!-Cr) FExpmau0l Datc) (Name of Contractor) Gn-7LUaB(-- Comoany/Po!im, Nunccr) (—Exiriion Dale) (Name of co=C10,) Omsurancz Compan)•/Pobcy Nunbcr) (Expiroon Datc) (Name of Contractor) 9zSUraAc-- Compauy/Policy Numlxu) (Expiration Datc), (and:Ai:;oca1 door if nca_—u�•to a�c?u�iaform+�•i oo p<ztniaias to..11 oocaac.n:-�) ( ) I am a sole proprietor and bave no one woridng for me. ( ) I am.a home o-,vner performing all the work myself. NOTE:pl=sc be.wart Lhe u•tz J 6emcouvcn�.t�o employ pcsona w do—Mn —,• cc—,r. 00 c rCpair.Or c ov.d%,ctL-Z of not mote th.a tr-rw_=re in-t oh the bomw mer r=id=or oo the gain zppt:rtcn,=the:-&-o,ooc Ica--ally oecrdmi w be r�tploycs uD?—the..=i;=A:�- e -a AG(GLI 52-=1(5)).apptirapoo by a bomcow oa far c(icy or perroit ra=y cvidmrx d-: IcgJ etxzu of.a axployo uoder die Worlceet Compcavtioo net I uodcra"d rho a oopy of this m 1c m„y be forwv ded to tha oogart—w of Inmatricl Ar+ &.=y otyoe of Ir>-�for the - oov--' t v Ti=1ioa and at--t L-Jum to Lc=m,covcra&c tmdct socGon 2 5 A of MOL 152 t7n Iad to the iztpox on ofaimiwd pca+I - oomitmg of a fiat of up to S 1300.00 and/or iurpcisoar�o f up to ooc yelr end civil pcautio in the form of a Slop Wort;Order. d a rim or S I DO.00 a d_y zpj=t>x _.... Far dcp.rta'=^_',u-only r permit Number - 'lvL ( tt4 7` �� , Map°J Lot SipDaWm of Lic=scc/Pcrmittcc �� Versionl.7 Commercial Building Permit May 15,2000 77� SECTION 10 STRUCTUJ2AL PEER REVIEW(78D CMR 110 11) Independent Structural Engineering Structural Peer Review Required Yes......❑ No...... SECTION iI OWN,ER AUTHORIZATION TO 8E COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUfCDING PERMIT rx, e, r as Owner of the subject property hereby authorize U) )?I Yli7 to k to act on my ehalf,An all matt.Qrs rplativ to work authorized by this building permit application. e';; , ^� atu of Owner Date I, � 1 ` ��� Ct YYl r) 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. C111LL / e4 /,tit C4dZ� JE° � �Yl Print 11 me- Signature of Owner/Agent Date SECTION 1 -CONSTRUCTION SE RVICES 10.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number y , Address Expiration Date Signature Telephone ERS"COMPENSAT AFFIDAVIT M 2SECTIOWK ION 5U ANCE ,aNv C(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...... +B" Version 1.7 Commercial Building Permit May 15,2000 SECTION 9 PROFESSIONAL DESIGN-AND CONSTRUCTION SERVICES FQR,BUILD{NGS'AND STRUCTURES SUBJECT T PURSUANT T0'786 CMR,116{CONTAINING MORE THAN:35'000 C:;F.AF:.ENCLOSED'SPAACE) 9.1 Registered Architect: Not Applicable ❑ Name(Registrant): Registration Number Address Expiration Date Signature Telephone 92 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor i"t ,`/-�i ,,� i a �� k ' �C yB i Not Applicable ❑ Company Name: a 1r'1 Responsible In Charge of Construction 7 Address -- Signature Telephone Versionl.7 Commercial Building Permit May 15,2000 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ 1 Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑ 8. NORTHAMPTON ZONING 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 arlan #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW y'rj YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT 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 ✓'� 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: L Versionl.7 Commercial Building Permit May 15,2000 , SECTION 4��ONS1i4�3�N�13�CfSQR�RR0,7ECT�LESS:�t1AN�5,t10D�r 'CUBIC FfE "`OFfNCL .SEflC 3 Interior Alterations Existing Wall Signs Existing Ground Signs Additions❑ Roofing f Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Accessory Building [ ] Repairs [ BRIEF DESCRIPTION: .5t)e-,r <e gilt 4, at//k xt,(.A,("d° SECTIONS-,USE GROUP AND CONSTRIICTiO1NTli'PE " USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly Io A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ I Institutional ❑ I-1 ❑ I-2 ❑ I-3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 56 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF 1DQSJ3NG�BiII7�1GND1tiOING REN01i' IONS, #DDONS PaNUOR'CHP,NGE.IN " Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): ji i SECTION-6BUIL•DIN6 IiEIGHT AN>D AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Lei" `+ S4 s a m _.. ,�, . . _ Floor Area per Floor , nd N � x tea, 2 3rd 3 rd m 4 4 9 nEiw "WHO ME Mt. �„ ,'' Total Area (sf) Total Proposed New Construction (sf) �� _ w Total Height(ft) — �; �a Total Height ft---------------- , ; - Versionl.7 Commercial Building Permit May 15,2000 qty orthampton ui epartment 2 in Street r ,u� 2 2004 0 100 North to , MA 01060 EV 7-124 Fax 413-587-1272 DE I ofKAM7tON,MA 0106 NO APPLIC N TO CONSTRUCT,REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING s =SECTION 1 SITIE TINFOR�IATIflN 1 1 Property Address. � � ' , `-�!' °SECTION 2.�PROPERTY OWNERSI�IPJAU�Ht�RIZIED°A6ENT `"" 2.1 Owner of Record: tk-`r`�_�1 et "'C lz"Is,C1 �.�. `� 'J 1) 54-17 t .` j /1-e"e rlle L'/eta Name�(Phnt)� '1 r,. Current Mailing Address: Signature Telephone 2. 1thorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTO MOST3 ECRUCTION COTS r Item Estimated Cost(Dollars)to be ,' Officiaftse Only completed by rmit applicant =' g Permit Fee 1. Building (a)Buddin 2. Electrical (lit Estimated Total Cost,"f .Constrt�ction.7*6 6> 3. Plumbing 81dmgerm�f fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1 + 2+ 3+4+ 5) r /G'G 1 G° edt.Nuriber n.. :. Tlh� Section Foie ciai Use",-nl Building`Pei -it"Number._ Date issued c ....Signature: B uilding:Cpmmission&/Inspectorof Buifldings, Data 1.47 STILSON AVE BP-2005-0106 GIS#: COMMONWEALTH OF MASSACHUSETTS a :Bl k: 17C-097 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0106 Project# JS-2005-0128 Est.Cost: $1100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: William Gnatek 100088 Lot Size(sg.ft.): 8929.80 Owner: WASLICK WILLIAM W&ANN T&JO Zoning.URB Applicant: William Gnatek AT. 47 STILSON AVE Applicant Address: Phone: Insurance: P 0 Box 204 (413) 584-5682 WC HADLEYMA01035 ISSUED ON.7130104 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP, RE-ROOF LOWER REAR FLAT ROOF WITH RUBBER ROOFING 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: FeeType• Receipt No: Date Paid: Check No: Amount: Building 7/30/04 0:00:00 1600 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo