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17A-054 (4) O 4.tttAMp�0 � a e a, Git� of 'Wlart4ailiptolt 9 6 f�ltcsaarhasctta' m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ' WORT{ER'S COMPENSATION INSURANCE AFFIDAVIT (IicenserJpermitiee) with a principal place of business/residence at: .`7 (phone#) 3: �P-n)R f (stre`t/city/stalr/np) do hereby certify, under the pains and penalties of penury, that O I am an employer providing the following workerjs compensation coverage for my employees worlang on this job: (lasurance Company) (Policy Number) (Expiration Date) (Iaam 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 Company/Poky Number) (Expiration Date) (Name of Contractor) (In_nlraace Company/Policy Number) (Expiration Dale) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml shtct ifne,ec—uY to inetude infornutioo pertaining to all oodsaeors) i (� a sole proprietor and have no one"Workin g for me. ( ) X am a home owner performing all the work myself. NOTE:please be await that whilo homcowDm who employ pcnom to do % ,�coastr i co or itpair work an a dwelling of not nxva than throe unit in which the homoowncr rciidcs or oa the gonad,appurtenant thereto arc not generally coondcrrd to be employers under tho vvor�oompcmaticu Act(GL152,ss 1(5)),application by a homeowva for a bc=c cc Permit may evidence tho legal rtatua of an amployec under the Workeez Compensation AcL I undenfand that a copy of this vWconcat may be forwarded to tho Dcparmxo2 of Indu b ial Aocidm&Of&oa of In wrxnoe foe the covaxge verification and that failure to secure coverugo under suction 25A of MOL 152 can Iced to the imposition of criminal Pcaalti- ooau3ting of a fine-of up to 51,500.00 andloe imprisoamrni of up to one year and civil pcnallia in the form of a Stop Work Order and a firm of S 100.00 a day against me. For caly Permit Number i of LicenseelPermiaze e SECTO'N$ CONSTRUCTION SERVICES 81 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder ` Skk�gc9/7 License Number zevziel AddL"S "-,A, Expirat4 Date Signat Telephone Re 'a, n Not Applicable ❑ Company Name Registration Number CV- Address Expiratiwf Date Telephone f SEC 100'r10-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. Homeowner Signature S CTIONS:`DES�C rliOFRR01?OSED YViORk Cxc'�aa ' licabie N b#ai' U�#K4;'b3 3 -� dx�N3NV9 W� 9i b SdS'Y h'tdM NRWR � New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: od Alteration of existing bedroom Yes No Adding new bedroom Yes ��N0 Attached Narrative 0 Renovating unfinished basement Yes fo� _No Plans Attached Roll ❑ - Sheet 0 G�Ifi Ne ho affA addition t exigsfing hh using, complbl&lieloTlo 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 O t CONTRACTOR APPLIES.r R BUILDING PERMIT r � �, ` PP as Owner of the subject property hereby authorize /C=c'�•��' ��'�i� / '`""' l� i,� '� to act on my behalf, in all ma relative to work authorized y this building permit application. yJ� 12 Signature of Owners Date ' as Owner/Authorized Agent her y declarelhat the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. SigRet9'Gnder the pains and penalties of perjury. Pnn ame rn `] Signa Date o /! 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 i/' YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW i/ 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: f Northampton B ing Department I Main Street S' oom 100 0-T 1 7 "t 2No� °� pton, MA 01060 phone 41587- 240 Fax 413-587-1272 Q -e l L>r;°T Ct B4Ji!C'?:G IhSr'ECT!�`�S � ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION-1 -SITE INFORMATION This section two be!completed 1.1 Property sby af�ftce P Address: Y Map Cot $ 1nit Zone �O�erlayDistrict Elm St:District CB Distract SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /h C,/'P-7 of !w^ Nam 'nt) - 1 Current Mailing Address:cor 64'�' dfz';P/` Telephone Signature 2.2 Authorized Agent: "z4zzl � NPrin Current Mailing Address: Sign Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building If,, Ci- (a) Building Permit Fee d 2. Electrical X (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/).;-' r This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2003-0399 GIs#: COMMONWEALTH OF MASSACHUSETTS 7 � 4 CITY OF NORTHAMPTON Lot:-00 Permit: Buildin#7 Category: BUILDING PERMIT Permit# BP-2003-0399 Project# JS-2003-0675 Est.Cost: $11000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: TIMOTHY SKROCKI 060967 Lot Size(sq.ft.): 22346.28 Owner: NORTHAMPTON CONGREGATION OF Zoning:URB Applicant: TIMOTHY SKROCKI AT. 165 BRIDGE RD Applicant Address: Phone: Insurance: 6 MILL ST (413) 529-0527 EASTHAMPTONMA01027 ISSUED ON:10117102 0.00:00 TOPERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE ROOF 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 10/17/02 0:00:00 1353 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo