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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AI A AVIT
I,
(license�/PeTmittee)
with a principal place of business/residence at:
_(phone )
(strt�t/ci ty/s�afr/a p)
do hereby certify, under the pains and penalties of perjury tha':
( ) I am an employer providing the following worker's com msation coverage for my
employees working on this job:
(Insurance Company) (polity umber) (Expiration Daze)
( ) I am a sole proprietor, general contractor r homeowner (circle one) and have hired
the contractors listed below who have the fo owing workers compensation policies:
(Name of Contractor) Company/Policy Number) (Expiration Date)
(Name of Contractor) cc Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Numb<:r) (Expiration Date)
(attach addit OQ21 short if to include iafortnstioo pertaining to alt 000frndors)
( ) I am a sole pr plietor and have no one worizng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be ware that whilo homcowo=who cmplay pazom to do rns i„r ,ac �ruC,ioo or rcpair work m a dwclag of
not more th n throo iia Vd2ich the hoamwmr residcs or oa the grounds appurtenant thx�o art nor Ccrxtauy coasidacd to be
employers 11 th6 workct .ration Act(GL152 ss l(5)�application by a homcow n r for a uccnsc or per if may cvidcnoc the
legal ctahu of an amp toyer undertho Workcet Compomation AcL
I understand thst a copy of this rta.tcmca may be forwntded to tho Doperwxat of Industrial Accidm&Ofhoo of lmiuwoa for the
oova-age vetificatioa and that failure to acct=coventgo under soctioa 25A of MOL 152 can Icad to tho ia>positioa of criminal pcaalties
oonsiuutg of a fine of up to S1,500.00 sndloe imgtisoamait of tip to one ycar and eivt7 pemltia in the form of a stop Worst order and a
firm of S 100.00 a day againA me.
For dq=W=W tuo only
Permit Number
Lot#
Siamtm-e of Licensee/Permitt:ee
SEGTIbN 8=�CONSTRUCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
V dyl License Number
Address Expiration Date
Signature Telephone
a
lissililim Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 Yli'ORKERS' 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"ce Tres and assumes res on ibility f c mpliance with the State Building Code,City of
Northampton Ordinances, Sta an Lo Zoning aw an tate of husetts General Laws Annotated.
Homeowner Signature
k � ?
�p � . pF PROPOSED cFickal a ' hcable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofingf
Or Doors ❑
Accessory Bldg. Jd 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❑
; ..I ;.+ ddtro'�n toexil;tin Thous°incolti 1e e;. h" ' :foilowi
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?
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
5ECTIONs .a OWNER AUTHORIZATION TQ18 COMPLETER WHEN
OkWN1=RS AC�ENT�OR CQN7RACTOR,.APPLIES FOR,l3UILbING PER
Via-
as Owner of the subject property
hereby authorize _ to act on
my behal , n all atters I e tow u horized by this building permit application.
Si ure of n 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
sue:.,
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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
fi
Lot Size G� 5c)i �,'
Frontage !/
Setbacks Front 7 7J(}
Side L: R: L: R:
Rear I /30
d
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&pavedj /��
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'.Y-ES,.describe size, type and location:
y of Northampton
DE ilding Department
12 Main Street
Room 100
a OCT " 1 2002 t ampton, MA 01060
hone 4 3-5 7.1240 Fax 413-587.1272
DEPT Of BUILDING INSPECTIONS
APPLIUAI TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This
1.1 Property Address: s
. x
Zo� ne la Dist �
Elm 5t°District_ ,. CB D, tr t F
SECTION r2- PROPERTY:OWN ERSHIP/'AUTHORIZED'-AGENT
2.1 Owner of Record:
N m (P Current ailing Address:
Telephone
ignatur /
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
c pleted 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 =0 + 2 + 3 + 4 + 5) ] Check Number t � '-
This Section For Official Use Only
Building Permit;Number Date issued:_
P
Sinature:
v
BuildiggCorm oroBICl gs , Dates ,
,
Y File#BP-2003-0349
APPLICANT/CONTACT PERSON KOLEMBA EMMANUEL J&
ADDRESS/PHONE 62 ACREBROOK DR (413)586-3629 O
PROPERTY LOCATION 62 ACREBROOK DR
MAP 29 PARCEL 076 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out _
Fee Paid c
Typeof Construction: REPLACE EXISTING 10 X 12 SHED, STRIP&SHINGLE ROOF
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,4MATION PRESENTED:
pproved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Commission Permit from CB Architecture Committee
Permit from Elm Street Com3ussion
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.
*Variances are granted only to those applicants who meet the strict standards of MGI,40A. Contact Office of
Planning&Development for more information.
lu
r . .
ox
. : BP-2003-0349
G1S#: COMMONWEALTH OF MASSACHUSETTS
�„;: .:, CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2003-0349
Project# JS-2003-0581
Est. Cost: $5700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor_
Lot Size(ss . ft.): 20821.68 Owner: KOLEMBA EMMANUEL J&
Zoning:URA/WSP Applicant: KOLEMBA EMMANUEL J &
AT: 62 ACREBROOK DR
Applicant Address: Phone: Insurance:
62 ACREBROOK DR (413) 5 _3629
F LO R E N C E M A01062 ISSUED ON:1017102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING 10 X 12 SHED, STRIP &
SHINGLE ROOF
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:
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 10/7/02 0:00:00 5135 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo