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d DEPARTMENT OP BUILDING INSPECTIONS �
212 Alain Street ' Municipal Buildinu
Northampton, Mass. 01060
WORK'ER'S COMPENSATION INSURANCE AF < AVIT
(li ccuscc/perrni ttcc) --
%vith a principal place o1-business i-esidencc at:
(stmt/ci ty/stair-/zi p)
do hereby certify, under the pains and penalties of perjury, 11t
( ) I am an employer providing the following worker's comocns Don cove:2ge ifor In)'
eluplovees worUng on tills job.
(Incur-;nc:� Comr=, (Polio;Nu_mirr) (r;xpirtion Dzlc)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors Listed below who hive the follo%ving worker's co»oen`anon policies:
(Name of Cout::3cror) (Iii-s-uranc'.; Company/Pchc-, NU-Min-) (XpII-w1on Date)
(Name of Contracior)--- (Insurance Company/Policy (`LxpLmiion Date)
(Name of Contnctor)-- (Insuranc: Company/PoUc} Number) -- (Expu-noo Date)
(Name of Contractor) (Insurance Comrnny/Pohcy Number) (Expiration Date)
(eaach additi ld cixc!ifno xiv to ii cku mfoRa n: pc�to ell c_o:�)
O I am a sole proprietor and have no One working for me.
I am a home owner performing all the work myself.
NOTE:p(csc tx aware th al a,trJc bourn"" ra wbo ciaploy pczocu to 63 a. c=-,:-sc_ioo c�rcp air work on.d,,cIh--F of
nrx aroec th_n Ltuoe uuitj in u1,iidr the kwmooaavcr midi -oa the fjout zppulteci zi thc�o a.c o-x,Ecxsa l y oec�id.-�cr1 to he
cniploym undo ccnipc=sm-lion Acl(GL152-s:5 1(5)�nppliratioo by a homcoc,),:T for c c v or permit r�.y c«drnoc trx
legal etxnic of an e,-rplovoc under dto Works ',Coaiponz..lioa A<t
I undasL,nd dw a oopy of thiu etat—ai.y bo fora nvdod to rbo DeSxirtmait of Offioo of L--oo for tl o
oovcn,gc vcrT1C:Uo0 and t11--t r=iltnt to saauc covcrasc under soction 2 5 A of MGL 152 can loiJ to tl>c i ,� ou of cnmia-d pco-lkia
ooci it g of a floc cf up to S 1 500.00 andrex iu2frT3, lri of up W 0r---yrsr and aai]penal a n tic form of a Stop WO&Ord-end a
fim oCS100.00&day tgziasl rD--
rOr(Sc;liStili_���UK«ily
Permit Number _--
1 Lot
siBnaturc of I,iccn_ctll'6 nitice - TSCe
*4 ' iI
SECTION 8-CONSTRUCTION SERVICES
i Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
E, � .... .«..' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.O.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.
ned 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 Signature ��Z ::;��
Ai
"'CT ION 5- DESCRIPTION OF PRO 'OSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)0 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Addin new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6 ? M .
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?Pv f
d. Proposed Square footage of new construction. Dimensions X
e. Number of stories? /� I
f. Method of heating? 42,.+s Fireplaces or Woodstoves Number of each
;41 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,AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property
IF I
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date 7 pcJ
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.
ned 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:
OPW-
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF YES, describe size, type and location:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 ae
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: This sec 110 to be completed txy office,
Map l.ot_ � :. 0nrt
Querayas#�� t
x ,
fiY' c fl lGt GB 0ric
f)tS
SECTION 2"-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C Gas T z. m ,4&4L-
me(Print) -t o-ri, l>e`o� Current,/ailing Add ,A t/
otli� Telephone 7
Signat e
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) Cheek Number 0fu4
This Section For Official Use Only
wilding Permit Number: (' TDatelssued:
Signature:
Building Commissioner/Inspector of Buildings Date
0 lb
File#BP-2000-1038
APPLICANT/CONTACT PERSON NIEDZWIECKI CHARLES J&KATHLE
ADDRESS/PHONE 19 BEATTIE DR (413)586-1624 Q
PROPERTY LOCATION 19 BEATTIE DR
MAP 29 PARCEL 205 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 Oy —
Typeof Construction: CONVERT EXISTING BASEMENT CLOSET INTO BATHROOM
New Construction
Non Structural interior renovations
Addition to Existinp,
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 presentedibased 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 C fission 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 public works and other applicable permit granting authorities.
19 BEATTIE DR BP-2000-1038
GIs#: COMMONWEALTH OF MASSACHUSETTS
+ Mg.-Block:29-205 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2000-1038
Project# JS-2000-1869
Est.Cost:$3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(sg. ft.): 1001 8.80 Owner: NIEDZWIECKI CHARLES J&KATHLE
Zoning:URA Applicant. NIEDZWIECKI CHARLES J & KATHLE
AT: 19 BEATTIE DR
Applicant Address: Phone: Insurance:
19 BEATTIE DR (413) 586-1624 0
FLORENCEMA01062 ISSUED ON:5117100 0:00:00
TO PERFORM THE FOLLOWING WORK.CONVERT EXISTING BASEMENT CLOSET INTO
BATHROOM
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 Sijjnature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/17/00 0:00:00 4700 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo