17A-282 (2) O 0
GXt7 Of 'Wart4aillptolt
$ 6 �trssscEinsftts'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01.060 '
WORKER'S COMPENSATTON INSURANCE AFFIDAVIT
(IicenseeJpermittee)
with a principal place of business/residence at:
(phone#)
(su=t/city/staiehip)
do hereby cerr-fy, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees worlang 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)
�f
(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 additioml sheet if noocssary to include info[mation pertaining to all eoahrndors)
( ) I am a sole proprietor and have no one woAing for me.
(, ( I am a home owner performing all the work myself.
NOTE:please be aware tfiai while homeowners who employ persons to do maiwmaac, udion or repair work w a dwelling of
not mote than throe units in which the homeowner rtsidm of on the grounds gpurtennnt therdo arc not gcocratly coondcred to be
employes under the wmkcrts oompcasatioa Act(GL152,=1(5)),application by a homeowner for a Gommse or permit may evidence tho
legit status of an employer under the Workeet Compemation AcL
I understand that a copy of this statement may be forwarded to tbo Depert m eed of Industrial A cidoa&Offioo of Inwrance for the
coverage venfscation and that failure to sea=coveragrr under suction 25A of MOL 152 can lead to the impositioa of criminal pcnahies
oomisting of a fee of up to 11,500.00 and/or iarprisoomcnt of up to one year and civil penalties in the form of a Stop Work Order and a
find of S 100.00 a day againa tne.
For dq=tncdsl uac only
Permit Number
Map# Lot#
SignaWre of Li ermittee e
�JETIION 8-CONSTRUCTION SERVICES
,.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
.. ;a;,. ova nu4e t(tt p^ �Mtt
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WQRKERS' COMPENSATION INSURANCE Af F113AVIT(M.G.L.c. 152,
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.
'gned 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 " dam/ C
+ e
u
SCR O P W h i' bie
New House 13 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 13
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: /1°E—St//ill6-E SdyTlJ S/QE vE .P�f= I�DD 0,4-4,W4 yewl, FtrP
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes / No
Plans Attached Roll ❑ - Sheet❑
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?
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
OWNE#$AGENT OA'CdklrOACi 00 APO' Iii Fd SUILDtNG PERMIT
I, 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
I, 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.
igned under the pains and penalties of perjury.
Print Name t
Signature of Owner/Agent Date
J. y
Section 4.
OW 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:
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 '`y 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:
. 10 + Y
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION -SITE''.INFORMATION
Tha section to be come d rY offi
1.1 Property Address: s
Map 3v nit '
9/ a
ss o p/ls,(n
4�p
SECTION 2';=PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ee�y�La '74•yD a iglus'f0 ,T�'. i B'�P/d G �Psy,O �-0. ."
Name(Print) Current Mailing Address:
Telephone
Signature JF
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 by ermit applicant
1. Building (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 Section for Official Use Only
Building.Permit Number: Date Issued:
Signature:
Building Comm isslonerAnspsctor of'Suildings,', Date'
191 BRIDGE RD BP-2001-0195
GIs#: COMMONWEALTH OF MASSACHUSETTS
r1a .Block: 17A-282 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Catep,oly:roofing BUILDING PERMIT
Permit# BP-2001-0195
Project# JS-2001-0316
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sa.ft.): 8450.64 Owner: JANDZINSKI DONALD J JR&MARY
Zoning:URB Applicant. DONALD J JR & MARY
AT. 191 BRIDGE RD
Applicant Address: Phone: Insurance:
191 BRIDGE RD (413) 586-5938 O
FLORENCEMA01062 ISSUED ON.8122100 0:00:00
TO PERFORM THE FOLLOWING WORK:RE-SHINGLE SOUTH SIDE OF ROOF & ADD
OUTDOOR VENT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
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 8/22/00 0:00:00 5281 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
i
191 BRIDGE RD BP-2001-0195
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-282 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0195
Project# JS-2001-0316
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size ft.): B450.64 Owner: JANDZINSKI DONALD J JR.&_MARY
Zonine:URB Applicant: JANDZINSKI DONALD J JR & MARY
AT: 191 BRIDGE RD
Applicant Address: Phone: Insurance:
191 BRIDGE RD (413)586-5938 Q
FLORENCEMA01062 ISSUED ON:81221000:00:00
TO PERFORM THE FOLLOWING WORK:RE-SHINGLE SOUTH SIDE OF ROOF& ADD
OUTDOOR VENT
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Final: Final:
Rough Frame:
Gas Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 19-vZ 8,--0 0 4vtQ/!O
THIS PERMIT MAY BE REVOKED BY THE CITY O NORTHAMPTON UPON VIOLA ON OF
ANY OF ITS RULES AND REGU IONS.
Certificate of Occu anc S.Ss' nature:
Fee Tyne: Receipt No: Date Paid: Check No: Amount:
Building 8/22/00 0:00:00 5281 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo