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29-151 r MF CtWrp� z0—�� i3 of R r� �\To� 1a 111 p foil t� RI&3%Rch n r r Its ' d DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Macs. 01060 WOMCEWS CONITENSA`IION INSURANCE AFFMAVIT I - -K - - c, (1;ccus�JpcFm;ttc�) \Vith a principal place of business/residence at: I r �" DIO3S (phone:') ( clty/staic�zip) do hereby certify, under tic pains and penalties of pegtify, ?hal ( ) I :man ernpioyer providing the followins� workc�s cornocns non cove.�gc for Inv eluplovccs wor�Ding On this job (In==c_— Corn=-,,) (Pork; Nurntrr) 0 xpirruon Dalc) ( I am a e proDretgeneral contractor or homeo4vver (curie one) and have hired the contractors listed below who have the fokwiog worker's comp n_,aaon policies (NQmc of con .Ci0 ) 011' mllc: coinpallyol d]C-c' �t 1SIlb r) ?:pUil00i? 1�11C) (Name of Contractor) -- (Insurance ComoaawPohcy Numcrr) (Expir,uon Date) (Name of Contractor) Qnsltrance Compan y/pouch Numbs) (E:pimuon Date) (Name of Contractor) (Iasuranc_- Comrauy/Pohcy Numbs) (L-xpitauon Datc) (naac},addi:iocaJ c'xC it nc�u:y to c>:?uc�infoll .:ioO pertn.inins to ntl X I am a sole propnetor and have no one wor}dtig for me. ( ) I am a home owner performing all the work myself. NOTE:pl�tic nw,t},e K1 tc hcrn n u+00 acErplay penes w 63 "ori;oo.C..clli:g of ant a>occ ttin tic==-rd in a ich the tY.Y ,O' Dcr rcado or 00 the p-0und3 hoc Cc> -.11y occJ:d to k w-ZPIayc3 unCc Lhc.�v;i:r�3 o�y�=line Au(GL1523a1(5)��{>ptintioo try n 6otncoava fc,c l:�`x a f'a"T°n rn:y cvrd•�oc tJ`c Icgar ctanu of na c toyer uodcr d,o WoA-_c ,Co�ncL I undasz;a.;dLi>ooyy of ttu.a>,t. r,r may bo foe _t3 d to rho DV—tn> of lt�.u-id Al d-.&Off,—of(r,�for the C0vcrnSc vcri6C:LO0 n_"d IlLt L•iitnc to cram covcT midcr sod oa 25A cf iAGL 152 an lad to the"-g>oiitiw of crimm-'1 Pcaittic3 0003iri of a rsM of tap to S 1}00.00 nI"dlcx=Pri3otm>eri of up W one year tr>l aril Pavhia n tz form of n Stop Work order and e biro of S 100.00 l a:y.Fp im1 me For ordy _ 1`bp., Lot Signature of Lic&sccll'cnniucc ��e i y r r CQ.I07 ftRTiQN.5ElICS, .,.1 Licensed Construction Supervisor: t Not Applicable ❑ Name of License Holder: keg"r, ®c ��`Gl 1/ � 051 3q,1 License Number Address Expiration Date 1 L,- 86 j Q Signature Telephone Not Applicable ❑ Company Name Registration Number (7 (�Log Address Expi artion Date Telephone 6Vn a;ECi°IQM 10�Yk?RK IiS'C©I IPENS�1T�r N`1NSU," IPE AFI:Ii gYIT(M.G L. 152,§2aC(6j) „ 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. �*gnecl Affidavit Attached Yes....... K. 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 Signature ti r Mu I New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work:-. f+Vti0 I Wb Ej vJC,�- pTf— _ ki Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative❑ Renovating unfinished basement Yes k No Plans Attached Roll ❑ - Sheet❑ ho 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. Mascheck Energy Compliance form attached? 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 AOTHORIZATION TTO BE OM ET 'ED WHEN OWN 1, S AGIENT OW CON ONTRAOT+ I,�I�Pk1 5 I+OR,NN�II:p1�1O PERMIT as Owner of the subject property hereby authorize ,"tV\ y\'ti QV( 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. igned under the pains and penalties of perjury. P 'nt Name ✓ Signature of Owner/Agent Date s • 4 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: . s Qi of Northampton ding Department 2 Main Street • 4 Room 100 � P tha pton, MA 01060 DEpTpFSU�a -1240 Fax 413-587-1272 I+Gtile .v, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECT ON 1-S.1TE IN RM1#7'[ON 1.1 Property Address: V4" © eb SECT[Ql 2 PROPERTY pwNERS1 11 7AUTH I I I D;�4GEMT 2.1 Owner of Record: to Name(Print) Cur en Mailing Address: 6 C- y d S U (ld/ / Telephone Signature y 2.2 Authorized Agent: KQIA U16, k 75 — 01035 r Na ee(� Print) Current Mailing Address: Signature Telephone Telephone 'R` S'E Tr s7lMATED�-a AU Item Estimated Cost(Dollars)to be official Use.,Only completed by ermit applicant 1. Building ' (a),Build Ing :ermt#Fee: 2. Electrical >k)Estimated To Cst3,tf oortstrU, onlfrt 3. Plumbing 4 ulldingt�rarmit 4. Mechanical (HVAC) 5. Fire Protection d 6. Total = 1 + 2 + 3 +4 +5 ( ) Check,1Viamber ilk :Build:ing l'ermitNur t: Date;lssued.,, 'S1Rnai te: Date Buil: 1ng.Gomm�ssioner11 .plc#orof;Buildngs. , 107 SPRUCE HILL AVE BP-2001-0066 GIs#: COMMONWEALTH OF MASSACHUSETTS MV.Block: 29- 151 CITY OF NORTHAMPTON Lot:-001 Permit: Building Cate o :roofm BUILDING PERMIT Permit# BP-2001-0066 Project# JS-2001-0108 Est.Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: .Quinlan Builders 101707 Lot Size(sg.ft.): 66646.80 Owner: LOSOWSKI MICHAEL J&LUCY P Zoning:URA Applicant. Quinlan Builders AT. 107 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 5 Hillside Dr (413) 585-0949 HADLEYMA01035 ISSUED ON.7118100 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 Occupancv Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 7/18/00 0:00:00 851 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo