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29-407 (3) WOW SECTION 8-CONSTRUCTION:SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9:Re isfeired Home liri rovertenY.Confiractor :v,_.. -;�; Not Applicable ❑ Company Name Registration Number /q Std re4di � �f Address ) Expiration Date C�� P•t 1 01(�� - eph Tel )one— �3 3— P SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIEJAVIT(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 buildine 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 ! L SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other Brief Description of Proposed Work: e k Alteration of existing bedroom Yes y/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _�No Plans Attached Roll -Sheet sa.^( New Fio�seTand o6,Additi6ii faezrstrnci tons � o tptef thMit"ing: 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? f. Method of heating? 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 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 WHER OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.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. Signature of Owner 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 the pains and penalties of perjury. Print Name Signature of Owner/Agent Date 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:� .�.e R:- � L: R:�... Rear Building Height Bldg.Square Footage % - Open Space Footage _ % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: _ _- tj (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES 0 IF YES: enter Book _� Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Date Issued: C. Do any signs exist on the property? YES Q NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q 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 © NO Q J IF YES,then a Northampton Storm Water Management,Permit from the DPW is required. Department use only City of Northampton StatrxsotPermrt ,3 Building Department CuttDOVewayrPerm► 212 Main Street SewedStrptrcAuarlabr� ' ty° Room 100 t#Aaailbdrty Northampton, MA 01060 Two Sets`of StructuraFPlans mph 413-587=1240 Fax 413-587-1272 Plot/Srte Plans ' Other S ecr `' APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY,DWELLING SECTION 1-SITE,INFORMATION ` 1.1 Property Address: This sectloo to be completed byoffice Salid� C4 Map Lot Unrt 77777! 777 7 777 777�L' Zone Ouer(a Drstrrct Eim SC Distnct CB.Distort SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT'` 2.1 Owner of Record: Si 0 Name(P' Current Mailing Address: Cr 13 " ,?6 - we Telephone Si nature 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 .Completed bX 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) Check Number This Section For-Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date 81 SANDY HILL RD BP-2007-1027 GIS#: COMMONWEALTH OF MASSACHUSETTS M Block:lh 407 ~ CITY OF NORTHAMPTON 10 Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2007-1027 Project# JS-2007-001656 Est. Cost: $1800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 20821.68 Owner: CZAPOROWSKI STEFAN Zoning:URA Applicant: CZAPOROWSKI_S_TEFA_ N AT. 81 SANDY HILL RD Applicant Address: Phone: Insurance: 81 SANDY HILL RD (413) 586-8634 (� FLORENCEMA01062 ISSUED ON.51112007 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE 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: dK THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAT I Certificate of Occupancy si nature: FeeType: Date Paid: Amount: Building 5/1/2007 0:00:00 $25.002376 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo