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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 "
WORKER'S COMPENSATION INSURANCE A_FMA.VIT
Ll ��/ifs/-' --/
(licenseeJpermittee)
with a principal place of business/residence at:
�(� T polye ..I..- . '-',- �7— 1 ;7W-M7 1fiC�N (phone#) `13 5,17 395
(stre--Uci ty/statch�p)
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:
(Laurance 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 folloWiDg worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
+r.
(Name of Contractor) (Insurance Compaay/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (F\pimtion Date)
(Name of Contractor) (Insurance Corap=y/Policy Number) (El-,piration Date)
(attach additional sicct ifnte,z. to include iafortnslion perta uin;;;n all�atzn on)
a
? I m a sole proprietor and have no one working for me.
( ) I am a home owner performing all the Nvork myself.
NOTE:please be awart that whilo homcowucn who curploy pazom to do M'![dcr�masnictioo or rcPair work on a dwelling of
not more than three units in winch the honaov n rt=dcs or oo the grounds aprurtcn th,:, t arc oo(D=,nr ly coc aukrcd to be
employes under the worker's aoaipcmation Act(GL152rs 1(5)),appLicatioo by a homconva for a liccose cc pclm may cvidcnoc the
Iegal rtatus of an employoc under tho Wockcez convomation Act-
I undcrstaud that a copy of this ctatcmcni may be forwurd«i to the Dcpertn"of Industrial A,:6&n&Offioo of Imsirwco for ttm
coverage vaification and that failure to&==covcragv undx—lion 25A of MGL 152 can lead to tha imposition of crimiasl pcu Wcs
oonsisti of a fine'of up to S1,500.00 and/or imprisouuxat of up to arc year and civil pcaaltia in the form of a stop Work OrdC and a
faro of 5100,00 a day against tty-,
For depu am er only
N
Permit Number
Mai I,ot#
Sipatmof Liccsee/Perr ittee e
SECTION 85=CONStRUCT1;ON SERVICES'.
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ✓l C L U i f L I ►/�/}LAI CL 1 ®17 /3
License Number
f( `��� i:y�'r, t1fiS �idr✓•°'1 I�r�✓-�' 0 Z2 f>c�
Address Expir tion D to
c� r,
Signature Telephone
Reg a e l om ' mprovement ,on a"cfor MR-7, ;J uffl Not Applicable ❑
/ .�?-3s-2V
Company Name Registratiion Number
^/ C e4l. t 7�5 2ov'3
Address Expiration Date
i1r✓C 5 'f Telephone Y13 3,27
SECTION 1U-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...... ❑
1 - t nom; O. near '�empt>la a
The current exemption for"homeowners"was extended to include Owner-occupied DwellinEs 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
t °
`SECTION 5 D�SCRIPTIONOPROPOSED WORK(check all aaplicafile)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] `Siding[ ] (Other [ ]
Brief Description of Proposed Work: Al e w 4 v a ff bo 2 cP en 1)J l` 5+-AND VP� �
Alteration of existing bedroom Yes No Adding new bedroom Yes —Z No
Attached Narrative❑ Renovating unfinished basement Yes x No
Plans Attached Roll ❑ - Sheet❑
Mf N ouse anii 6MMd'iti611171 xistang l 'ousing,_d6ft1e"te he::follo vin :
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? 2--
f. Method of heating? 7ZPIC- 0 LLrt&!t4 Z Fireplaces or Wood stoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction 1c,
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 ORYCONTRACTOR APPLIES FOWBUILDING 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.
Sign ure of Owner Date Q
as Owner/ thorized Ag
that statements and information on the foregoing application are true and accurate, to��af my—
hereby'declare
knowledge and belie .
Signed under the yains a penaltis f perjury.
�VICA �� ���
Print Name
Signature of 4Ownegent Date
r ,
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 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:
F �
City of Northampton
1:2 uilding Department 212 Main Street Room 100
thampton, MA 01060 587-1240 Fax 413-587-1272 Ot RUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATIONr
This secti6n�to be;comptetedby office�
1.1 Property Address:
R"nat � �
���/j�?�,,✓� Zone Overi�ay Distrrct� �� � "�
Elm st:District" ` CB Distiict�
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
1 Owner of Record:
A�
p �C
� r
/ION S S
NPrint) mr Current M iling d ress:
I
Telephone
Signature
2.2 Authorized Agent:
I C H o t L MAT 2(5 h o rJ l D '/6r 4Aw" ,J
Name(Print) Current Mailing Address:
�lj3 S,;! "7 3iS
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: _ P�� ` �� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date-
r ,
File#BP-2003-0273
APPLICANT/CONTACT PERSON MICHAEL MATRISHON
ADDRESS/PHONE 10 STRONG ST (413)527-3959
PROPERTY LOCATION 63 STRAW AVE
MAP 17D PARCEL 028 001 ZONE URB
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: REPLACE TUB W/SHOWER&NEW SUBFLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074136
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 C ssion
Signature o uil mg fficial Dat
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.
t
BP-2003-0273
GIs#: COMMONWEALTH OF MASSACHUSETTS
t 1 .,., CITY OF NORTHAMPTON
Lot: -001
Permit: B u i I d i g
Category BUILDING PERMIT
Permit# BP-2003-0273
Project# JS-2003-0475
Est. Cost: $500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL MATRISHON 074136
Lot Size(sg. ft.): 18033.84 Owner: MERSKI FRANCES A
Zoning:URB Applicant. MICHAEL MATRISHON
AT: 63 STRAW AVE
Applicant Address: Phone: Insurance:
10 STRONG ST (413) 527-3959
EASTHAMPTONMA01027 ISSUED ON:9123102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE TUB W/SHOWER & NEW SUBFLOOR
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 9/23/02 0:00:00 2216 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo