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cfl DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(Iicerlsx/permittee)
with a principal place of business/residence at:
(phone#)
(streeucity/stawzip)
do hereby certify, under the pains and penalties of perjury, 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 Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additieoal s cct ifntccniry to include information pertaining to all oodractors)
( ) I am a sole proprietor and have no one wonting for me.
J I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowum who employ persons to do xin we om:j;t cc or repair work on a dwelling of
not moee than throe units in tzttich the horwouvcr resides oc on the groin appurtenant therdo arc oot gcrnrally 000sidacd to be
employcrs under the wcxiccr's o<xrr�oa Act(GL152,ss 1(5)�application by a homcowocr for a lions-cc permit may evidence the
legal etatus of an employer under the Workers Compomation Act
I undcrrund that a copy of thin ctatcmcni may be forwarded to tho Dtpnrtr�of industrial Accideaty Offioo of I¢au*nca for the
coverage verification and that failure to Sarre covermgo unckc section 25A of MGL 152 can lead to the imposition of criminal penalties
000iLvIng of a fine'of up to S1,500.00=Wor impr-isonmcrrt of tip to one year and civil Pcaattia in the form Of ft Stop Work Order and a
fins of S 100.00 a day agai¢A mw
For depsrtarntsl uao Only
Permit Number
Ivfa 41 Lot#
yY i f Liccnscelpermittee e
Q
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
SECTIQN 10, WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG.L. c. 152, §25C(6))
�. z. . , ,
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.
-?6-11-0meowner Signature e4
" k �r7i1xA € P NAI t33aa� a
New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing ❑
Or Doors ❑
Accessory Bldg. J�' Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narr :live El Renovating unfinished ?',asement Yes No
Plans Attached Roll ❑• Sheet❑
e o se i'd- `�d t o e iii .
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 Ta r OWNER AUTFIORIZATION 'TOAME COMPLETED'°WHEN
OWNERS AGENT,O,R CONTRACT02'APPIIES'FO,it BUNGDING 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.
PA,LS ,
ature 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
3
Lot Size 7" c2 Id i ozry
Frontage
Setbacks Front
Side L: R: L: R:�
Rear
Building Height 7
Bldg.Square Footage %
Open Space Footage % lP
(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
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
\y r C Northampton
y it i g Department
Main Street
II oom 100
JUL 1 i 20002
NJ'than pton, MA 01060
! 87 240 Fax 413.587-1272
1;EQT Cf BU� ,r�i ECi
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SEOTfON 1 -SITE INFORMATION.
This ec o
1.1 Property Address: 3"
i z4f z
ZAP
k
ElrnSt District B "
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record: / _
t ld r e .�.
Name(Print) Current Mailing Address:
7 S y—� 0 d 7
Telephone
S' ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -'ESTIMATED CONSTRUCTION CO5T5-
Item Estimated Cost(Dollars)to be Official Use'Oniy
completed by ermit applicant
1. Building (a) Building Permit Fee
00 , 0Q
2. Electrical (b) Estimated Total Cost of
N 0 Construction from' 6
3. Plumbing Building Permit Fee
N C�
4. Mechanical (HVAC)
5. Fire Protection N
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building;Commissioner%Inspector of-B6ildings Date ,
File#BP-2003-0057
APPLICANT/CONTACT PERSON PAWLOSKI JAMES W&JEAN K
ADDRESS/PHONE 60 CLAIRE AVE (413)584-7007 Q
PROPERTY LOCATION 60 CLAIRE AVE
MAP 17A PARCEL 122 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out _
Fee Paid
Typeof Construction: CONSTRUCT 12 X 24 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE�FO LOW ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commiss'
�• d�_�
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Now
BP-2003.0057
GIs#: COMMONWEALTH OF MASSACHUSETTS
1mk:'1 , 122 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate o . BUILDING PERMIT
Permit# BP-2003.0057
Project# JS-2003-0137
Est. Cost: $1700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sg.ft.): 31276.08 Owner: PAWLOSKI JAMES W&JEAN K
Zoning:URA Applicant: PAWLOSKI JAMES W & JEAN K
AT. 60 CLAIRE AVE
Applicant Address: Phone: Insurance:
60 CLAIRE AVE (413) 584-7007 O
FLORENCEMA01062 ISSUED ON.7118102 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 24 SHED
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 7/18/02 0:00:00 805 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo