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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060
WORKEWS COMPENSATION INSURANCE AFFIDAVIT
I,
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(st=UCity/staW7ip)
do hereby certify, under the pains and penalties of pedury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working 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)
(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 shad ifnecenmy to include information pertaining to an ooa radors)
O 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 that whilo homeowners who employ pasoas to do construction or repair work on a dwelling of
not more than throe units is which the homeowner resides or on the grounds appurtema thereto are not gener24 oons�to lx
employers under the worker's oompauation Act(01,152,ss 1(5)),application lry a homeowner for a Cause a pcmit may cvidcom the
legal status of an employer under the Worker's Compamation Act
I undastaad that a copy of this uatement may be forwaa ed to tbo Department of rndrrstrid Aaidea&Offioo of Ltsuranoe for the
coverage vmficatioc and that failure to&cane coverage wxkr section 25A of MGL 132 can lead to the'imposition of cttiminal peaaltios
oomisting of a fine of up to$1,500.00 attdlar immbonmerd of up to one year and Civil pemlties is the form of a Stop Work Order and a '
firm of 5100.00 a day against me
t
i
For dgmt nutd use only
Permit Number
j� Mao Lot#
Signature,of Licensee/Permittee y
f
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
��e�eu�E. � � i< < « 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 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 Signatur
S9QTIQN 5- DESCRIPTIQN QF RRQeQAEQWORK(check all a I`cable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
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 v
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?
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
1, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters re tive to work authorized by this building permit application.
Signature Owner /J Date S Za a
, 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.
Print Name
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 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:
.. _...y
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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 I EMO ISH A ONE OR FA L WELLING
rim 01
SECTION 1-SITE INFORMATION �! a
1.1 Property Address:
s se+ io t � e +
tom,
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Map LO, Unil ,
Zonis / 6 w i
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SEC'TION=2.. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
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
com feted 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) Obi Check Number
This Section For Official Use Only
Building!Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector Qf'!Buildings Date
'Wile#BP-2001-0858
APPLICANT/CONTACT PERSON STASZKO EUGENE M&JOAN M
ADDRESS/PHONE 31 CRESTVIEW DR
PROPERTY LOCATION 31 CRESTVIEW DR
MAP 29 PARCEL 464 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid qu
T_ypeof Construction: INSTALL ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existinp,
Accessory Structure
Buildina Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FoOLLOWING 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 ion Permit from CB Architecture Committee
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 publi%works and other applicable permit granting authorities.
BP-2001-0858
GiS : COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Cate QOry: BUILDING PERMIT
Permit# BP-2001-0858
Project# JS-2001-1593
Est.Cost:$3000.00
Fee:$25.00 PERMISSIOIV'IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(s_1c.ft.): 10018.80 Owner: STASZKO EUGENE M&JOAN M
Zoning_URA Applicant: STASZKO EUGENE M & JOAN M
AT. 31 CRESTVIEW DR
Applicant Address: Phone: Insurance:
31 CRESTVIEW DR
FLORENCEMA01062 ISSUED ON *1
TO PERFORM THE FOLLOWING WORK:INSTALL ABOVE GROUND POOL
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 Si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building J I 1479 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo