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