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u -d DEPARTMENT OP DUILDF-�\'G INSPE?CTlol.'S —`
212 Alain Strect ' Municipal BuildinG
Northampton, Mass. 01060
tip'0111a,IZ'S CEONQ'CNSATION MSUR -NCF AFIqDA\gT
(I i ccvs;rJ perrni t tcc)
\l.-ith a principal place- of businesslresidence at
CG � �1/
� oc-'!)1/0
(sa-=vci ty/staicla P)
do hereby certify, under the pains and penalties of perjury, that
( ) I a-M an employer providing the- followino worker's compcns:_,ion cove,agc for Inv
e-tuployces wori.tlg on Lins job
(Iasur� Corsr n.) (Pohc; N r) ------ (r:'pir,uor, Dare)
( ) I am a sole proprietor, general contractor or homeowner (circle one) aid have hired
the coot:actors listed below vyho have the foUoWing worker's co[i n auon policies:
(1`71IllC 0. CO"':'Ci0") ttllR!r3nC,^. COI➢Dail '/hGUC}' NL1illrr, t-�-)�t1lGp� D,IC
(Na_rnc Of COntTZICiof) (IJiStll'a-ncc CompanwPok—y Numcrr) (LXpilrlicn Datc)
(Natne of Colorado,) (tRSUFa-QC Company/POliq Numb r) (Expifrmq Datc)
(Name- of Contactor) (Rsutanc�z Comcan-y/Pohcy Numb:r) 'E LI ion Darr)
(&Ul'Ch-d�f;ocil c'.ud it need.^ to�nc_�uc mforaii Co pCr�to.L
( ) I am a sole propnetor and have no one working for me
I am.a home owner perfor-i=', all the work myself.
l NOTE:plc be eware(Lam: ial.hcc- oOlm- to cu Icy pczoni w 6:) c rc�,aa..ork o3 t d.•c1L E of
and nKtT Ll,"J L'fR-L=?,In\dill Ct]ltx lX1LIX O'.vD�Y r'Q16�OC 00 the CrOUDd3 2 T11b—C D e..'2 DO(CC 11V Cc :6_.' to Ll-
cmploycT one's Lhc\.o 3 =lim Aa(GLI52_�3 l(S)�-pplincioo try a bomcoa�fcr:Lcrrl_�a prnn t c y c\id_ncc tf:c
1cg n,^.of na-ployx uadcr dw Woke,,C«npcaa.l Ad
I u-d-t. d the a on of thi.z>lema t m.y ye-fo.-xt ceded to Lb.D,,P�of Indu,,jd Amd.&Offioo of lrivr.DOO foe-Lb.
oovccnSc v<rif nIi a--'L"JLnc w coatrc'oovcTy undrr soO i OQ 25A d M01-152 m lad to the ice,ozi -of critnin_il pcn+l -
000iiz ag oC■fine («p to S 1-5 00.00 ar Ncx�iwarn o up to one yea,rod a�i1 pm.hio in 6e-form of a Stop Wo.k Order and a
rim of 5100.T--/fL,y L&&=x l
ForPcrmll11t1IDtxl
1.OP"" Lot s i n c cnscCA3c rnu cc —�a�
t
SECTIQM q 8 GONSTRUCTION,.SER1/IC5
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
y= Not Applicable ❑
Company Name Registration Number
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....... ❑ 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 and this permit.
The undersigned"homeowner"certi s and assumes responsi t�i mpliance with the State Building Code,City of
Northampton Ordinances, State an cal Zoning Law to husetts General Laws Annotated.
Homeowner Signature
r
SCRIP IOW0 PROPOE
i
NO...{., d
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑ 1 10 =C -
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Wor Az2a 4�M O
Alteration of existing bedroom Yes No Adding new bedroom Yes No U �
Attached Narrative❑ Renovating unfinished basement Yes No bouwe
Plans Attached Roll ❑ - Sheet❑
M,tW e .a,�.� ' d "o � " iii__ "",e li f6,11'6*,ire
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: S Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. 3 5A 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
S�ECTION�7i, 'OWNER AUTHORIZATION,-TO BE,.COMPLETIED WHEN
QWNERS AGENT OR`+CONTRACTOR APPLIES TOR BUILDING'PERMIT
-__3 1 ' as Owner of the subject property
hereby authorize to act on
my behalf, in all ma rs relative to rk a t by this building permit applic tion
7
Signature of 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 th pains and penalties of perjury.
-- t�
Print Name
� P-t// !17/V
Sign atur r get 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
i
Lot Size 1,4
r ?�Frontage �
Setbacks Front r�c� f �/�/ 30
Side L:9� R: 3a L: Y1 R: �
lS
Rear V7 3/ 30
Building Height
Bldg. Square Footage /f5 % O
Open Space Footage % i
(Lot area minus bldg&paved 6
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 y 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 G y'-` N rthampton
n 11,g Department
2 ain Street
m 100
`a
North mpton, MA 01060
DEPT OF R '/ 12 0 Fax 413-587-1272
NORTHAMPTON,MA 01060
rt
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to bexcompleted by office
1.1 Property Address:
UO
� a u
s y
r
/�LG>f �U �/Gf� ZoneOrfey District
Elrn St Districfi CB Dist"riot
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone y
Signature
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
co feted by ermit applicant
1. Building G �j (a) Building Permit Fee
2. Electrical GJ (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.Onl
Building Permit Number: h Date Issued:
Signature:
'%Jjdiipg 6mmissioner/Inspector of Buildings Date
s
Ale#BP-2001-1033
APPLICANT/CONTACT PERSON SLEZEK STEVE&DIANE
ADDRESS/PHONE 40 CRESTVIEW DR (413)584-1975 Q
PROPERTY LOCATION 40 CRESTVIEW DR
MAP 29 PARCEL 452 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 16 X 22 DECK
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 LLOWING 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 Conservation Co ission Permit from CB Architecture Committee
2Oo
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.
40IEW I}R BP-2001-1033
CIS#: COMMONWEALTH OF MASSACHUSETTS
M :Bl _:29,-452 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Deck Addition BUILDING PERMIT
Permit# BP-2001-1033
Project# JS-2001-1836
Est. Cost:$4800.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq. ft.): 1 001 8.80 Owner: SLEZEK STEVE&DIANE
Zoning: RA Applicant. SLEZEK STEVE & DIANE
AT. 40 CRESTVIEW DR
Applicant Address: Phone: Insurance:
40 CRESTVIEW DR (413) 584-1975 ()
FLORENCEMA01062 ISSUED ON.61141010:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X 22 DECK
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 6/14/010:00:00 411 $100.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo