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DEPARTMENT OF BUILDING INSPECTIONS ,
\ :
212 Main Street • Municipal Building ° °l`
Northampton, Mass. 01060 to”
WORKER'S COMPENSATION INSURANCE AltFLlAV1T
I, w' _ -5...2 vt. F n
O iccnsecIpermitt )
with a principal place of businessiresidence at:
C \ QJ- tl 1V. a & I) �,-\ (phoned) 54, -It 1' 3
(sIIef_t/ci ty /staic'zi p )
do hereby certify, under the pains and penalties of that
( ) I am an employer providing the following workers compensation coverage for my
employees working on tins job:
(` ��.,zD _ 5A-wC q Olie— _ - co
(Iasij Tina.- Company) (Po!icv Number) ( •;pirtion Dare)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have lured
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company Polic-; Number) (fix :ainiaon Date)
(Name of Contractor) (Insurance Company /Polio' Number) (Emir ion Date)
(Name of Contractor) (Insumnce Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compasry'/Policy Number) (Expiration Date)
(attach additicm-+l shed if neccnury to n c.'tek inform -anon peatatrung to all contra ntts)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware tha1 wile homeowners wbo cr ploy persooa to do cr...intenanc., coas ue oo er repair work on a dwelling of
not mac than three cants in w'l ch the bomrxcwner resides oc on the grounds appurte the,-eto art not generally coesidcred to be
employers under the weeker'e o pcnetioo Act (GL152..= 1(5)), application by a homeowner for a license or permit n_.y cvodcnce t c
legal manse of an omployor under the Woriccx'a Co maaiion Act_
I understa that a. copy of this etatcracai may bo forwarded to the Department of laeh, A eadea& OfGoo of lcair>awc for the
coverage vgjficItiec and that L•ilurc to secure (overage under section 25A of hiOL 152 can Icad to the imporitioe of ciminal penalties
cooeLstmg of a fine of up to S1,500.00 and/or caprisoemcat of up to one year and civil pcoa ics in the form of a Stop Work Order and a
fins of 5100.00 a chy tgiinA tnc
For dcparurri Kal uac only
rhi Li`7 /_ PcIllt Number
3 *w Map° _ - Lot n _
Si gnature of LiocnscdPc rm.iuee Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : V• A\fsvc.AL 44 ) tf•02.IW . 6 3y`�
License Number
\se QS) `� � � , wk- m'a7t3 y saS - 01
Address Expiration Date
Signature Telephone
Re 14���d IOM lam roremeitContractor t " r V 7?
!; P � €� -�_.� � � ,,..�� �=�, _���.��� �. = Not Applicable ❑
S v vz.w" 1v. \ \&.-e czS d L1�1 �o
Company Name Registration Number
� v E 1- -15 00
Address Expiration Date
Telephone
SECTION 10- 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 K No
11:tat, Ome awner,EX.em1A1014
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
SECTION 5- DESCRIPTION OF PROPOSED' WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)X Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks ( [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: ' o�� C & Q "t04)\c. F' "- Q".., v„.
Alteration of existing bedroom Yes No Adding new bedroom Yes )c No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
1f New how's ff of aci` lit bittcr ire irig ho i'sfne ;vtoiri tote th640' Ibwi :
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? V\b
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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 /2 MAO- Ctrel,",-/ , as Owner of the subject property
hereby authorize `4,2-A to act on
my behalf, in all tters re to work authorized by this building permit application.
c7.37C, 5.. - B-+tE3-
Signature of Owner Date
I, %AAvaye_ J , 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.
\Aw > "'¢.wt \V'
Print Name /7
Signature of Owner /Agent 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
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 K 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:
\\D � W, ,1411 ' � ��. .a ^ .� � 7 r Y � �' - a city of Northampton � �� � ��� °
Building Department it . Y �i � . ..
i Ti 212 Main Street . ' =t-f1
x Room 100 ' h ,
F ^r Qf t> tor mpton, MA 01062, * 0 ,
p one 413-587-1240 Fax 413-587.1272 .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This
section to becomQldted by office
1.1 Property Address: ; x
1�Qo CC) I,b t�ti
V \ti zone O lax District
Elm St. District _ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1. Owner of Record:
3 g0'CZ V p \N tL D \(\ .A vC ,UN -e--\\L 0 es-t,,,\ E
Name (PrrVVnt) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
1
dY1 wsec' j y N v z _ i c 1 ?,55 I I.) (l ' S 40.1-\ scs( 73
Name (Print) Current Mailing Address:
5 - 1 -7 1
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit 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) 5 6 poCj . Check Number
This Section For Official Use Only
Building Permit Number: .6 7671 Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
1
File # BP- 2000 -0769
APPLICANT /CONTACT PERSON Mark Sarafin
00 ADDRESS /PHONE 81 Russellville Road (413) 527 -7812
PROPERTY LOCATION 45 GLEASON RD
MAP 18C PARCEL 103 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 /(5)3hd
Typeof Construction: REMOVE & REPLACE EXISTING SHEETROCK/PANELING IN BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 053434
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and /or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received & Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § w /ZONING BOARD OF APPEALS
Received & Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w /ZONING BOARD OF APPEALS
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 Conser '<on Commission
/ � ,Y
Signature of Building Official Da e
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.
•
45 GLEASON RD BP- 2000 -0769
GIS #: COMMONWEALTH OF MASSACHUSETTS
v1ap:Block: 18C - 103 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: Non structural interior renovations BUILDING PERMIT
Permit # BP- 2000 -0769
Project # JS- 2000 -1440
Est. Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Mark Sarafin 053434
Lot Size(sq. ft.): 7143.84 Owner: MIROSHNICHENKO IGOR A
Zoning: URB Applicant: Mark Sarafin
AT: 45 GLEASON RD
Applicant Address: Phone: Insurance:
81 Russellville Road (413) 527 -7812 Workers
Compensation
SO UTHAM PTON MA01073 ISSUED ON:3/14/00 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE & REPLACE EXISTING
SHEETROCK /PANELING IN BASEMENT
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 3/14/00 0:00:00 1083 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo