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38B-217 (2) .5 - 6 „,,../T - _, t t 5114tA i 0 1o' /Li'' eR 4 amaNk is 3t .9 I( 4* 1 1 N) ) 7^(1 / _ .. i A Lft A . 1, DESK LINED PAGES ©1993, 1999, DAY - TIMERS, Inc • •00°.#1">#"##"' 1 ice �.orrirreoriweuiiri of lrluNxuc11143e113 _.,. I Department of Industrial Accidents '— 7 :7 Office of Investigations 1 Congress Street, Suite 100 4 111M SO _ _ = Boston, MA 02114 -2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organizationllndividual): - 0; 0 Address: \Z3 V e ri) ( e - A Q. t3o Zc - 1 mac: ; f i r % t4 e e ta Yk -,5 5. City /State /Zip: .K.)0(1 K et d ► �� 6 /16 Phone #: L 1/ 3 - 230 - Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. ❑New construction 2. p I am a sole proprietor or partner- listed on the attached sheet. 7. [W Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. II Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. 1. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State /Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and /or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiL un ' er t pai a d penalties of l erjury that the information provided above is true and correct Signature: WAI I�` Date] ' / 2 . Z.• Phone #: 03_ - Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : DLO t c, ( 3 )(17in5/c. t C5 - / 0 0 License Number 123 Deiit ( Q«,:' ���YIC'tlJl Ack55 ()ICU, 1 e0 � 1 J�� 7 201'5 Ad ss Expiration ate '/l 3 - - z30 - 9/670 Si nature Telephone 9. Reuistered Home Improvement Contractor: Not Applicable ❑ Cpl I-in Company Name Registratio mber 4 • - 1 y a Address Expirati." D. e 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 1 No ❑ 11. - Home Owner Exemption 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) El Roofing 0 Or Doors ❑ Accessory Bldg. ❑ Demolition New Signs [0] Decks [0 Siding [0] Other [d] Brief Description of Proposed / r" Work: e 0 - 1 Ct'1C "JM Q 2. i" 1 " ■N i - tt/1 l Alteration of existing bedroom Yes X No Adding new bedroom Yes I< No Attached Narrative Renovating unfinished basement Yes ic No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: 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? 5 d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? 5Ctavr Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes j\ No ► "�t j. Depth of basement or cellar floor below finished grade 1 ' U7 k. Will building conform to the Building and Zoning regulations? X Yes No . I. Septic Tank City Sewer x Private well City water Supply X SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AG R CONTRACT/RR APP�lIES FOR BUILDING PERMIT Z-vnA4-4C T�1 ! 3 f .� f I, Le_ Il 4 c 1 , as Owner of the subject property hereby authorize -1 DC+,191D t ‘ 5`c-T+ to act on my ehalf, in all matters lative tp ork author by th bu permit application. Signatur Owner Date c ,i( 2_ I, Pe 0 J44g 60Zl�S1 , as Owner /Authorized Agent hereby declare that the and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under he pains and penalties of perjury. au 17 L c (J�IAa` , k1.- Print Name Signature •f • ner /Agent Da Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 0 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO pC DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 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: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO O IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: RECE VED_ Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability III Room 100 Water/Well Availability 2 9 2012 Northampton, MA 01060 Two Sets of Structural Plans _ ne 13- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans DEPT. OF BUILDING INSPEC IONS NORTHAMPTON, MA 01060 Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office 222_ 5UUt r') 3'- Map Lot Unit 1v'4' 1i1(-t.vie‘ti IL& c&S i • C \ OL Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: / ['' l Name (Print) Current Mailing Address: Telephone // Signature '� �'� I l �J 2.2 Authorized Agent: Dcto :) 0. k• ?C). '? ZOy 13. titf . e(a mass o(ak Name (P t) / Current Mailing Address: '' i .� Y13Z; Sign. rfre Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building it 6.600 (a) Building Permit Fee 2. Electrical ZGrG (b) of Construction from (6) 3. Plumbing , ,,_� 0 Building Permit Fee 4. Mechanical (HVAC) �; 11(.' 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 1 /0, 000 Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -1050 APPLICANT /CONTACT PERSON DAVID JAGODZINSKI ADDRESS /PHONE P 0 BOX 204 NORTH HATFIELD (413) 230 -9160 PROPERTY LOCATION 222 SOUTH ST MAP 38B PARCEL 217 001 ZONE URB(100)/ 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: RENOVATE KITCHEN & ADD FULL BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 106068 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION 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 Commission Permit DPW Storm Water Management -mQli ' n Delay e of Buil ing'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. 222 SOUTH ST BP- 2012 -1050 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 217 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -1050 Project # JS- 2012 - 001810 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID JAGODZINSKI 106068 Lot Size(sq. ft.): 6838.92 Owner: BASILE LEONARD J Zoning: URB(100)/ Applicant: DAVID JAGODZINSKI AT: 222 SOUTH ST Applicant Address: Phone: Insurance: P 0 BOX 204 (413) 230 -9160 NORTH HATFIELDMA01066 ISSUED ON:6/1/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN & ADD FULL BATH 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: FeeType: Date Paid: Amount: Building 6/1/2012 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner