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35-295 (5) o S 't - �. LL LL qi b � D CIS n t u. t � I 0 t ` k e 04"���PTD a� °a Crx� �� �Drz#l�ttllt��ull - �aSaatl�ttSttha m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT I, D V ACF;uc,A (liCenscr/permittee) with a principal place of business/residence at: G r4ATA-' r-D Al. H47F1'fL9 A4q-S.5 (phone#) _a.Y7 (streeuci ty/stat dzi p) do hereby certify, under the pains and penalties of perjury, that: ( ) I am an employer providing the following worker's compensation coverage for my employees worlang 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) r (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compaay/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additiomt short ifneocnary to inchide informarion pertaining to all ooatrecots) ( 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 awaro that whilo homeowner who employ persom to do maintcuaaa,co str ioa or repair work on a dwelling of not more than throe units in which the bomeowner resides or oo the grouns appurtenant ibex to arc not generally considered to be employtra under the workers oompecsstion Act(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the legal clams of an employer under the Wodroes compomatioa Act I understand that a copy of this ssatemerd may be fbrvmx ded to the Ikpartmco2 of Industrial Aomdm&Off oc of Insurance for the coverage verification aad that failure to secure coverage under section 25A of MGL 152 can lead to the impos6oa of criminal penalties oonsisting of a fine of up to S1,500.00 and/or of up to one year and civt7 pcaahtia in the form of a Stop Watt Ouch and a fine of 5100.00 a day agniast the For dgmtme�tnl use only permit Number ' Map#-- --Lot# Si 4L ermittee EC'TION;S»CONSTRUCTION'SER""VICES I Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: V A v I O A - V 14CN U `A- © Y 9 FY6 Licens Nu er t&AN roe./, K A fdi-T f e eC d -:Z- Add res Jp/ationtate Sign NJ Telephone Not Applicable ❑ q Company Name Regis ation Number V4vI4 A _ V4C14 yC.4 Cf C1 Address Expi tion ate 6 y PA �-T" r O N• NATKIn Telephone `f?`Iry V-Y SECTION 1 111-WtflRKERS'COMPENSATION INSURANCE"AFFIDAVIT(M.G.L,c.152, 25C(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. ' 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 } GT N If DgaCJR1fJJQN QF PRO D O KLCh9ck All a i Itcabte New House ❑ Addition ❑ Replacement Windows Alteration(s) l9' Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: F/ti+s14 10 o k—rl3.0 O C- 1?A5f-4 fU- 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 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 5tCTIO,Kla OWNER AlUTHORIZATION w TO BE.COMPLETED WHEN 0WNORS AGi Vii?T Oiht d"ONT ACTCtFt APPLIES irO BUILbiNG PERMIT I, �e l el as Owner of the subject property hereby authorize A v t D lI. V Vkc 64 U<L A to act on my behalf, in all matters rel, i to,�vork autho 1pied by this building permit applicatio , Signature of Owner Date I, t1l A v ID p : V 4C OUC 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. 0V t p A . VAC 0v L4 Print Name It 7 /01 Signatur wner nt Aate 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: City of Northampton Building Department §_y` 212 Main Street k Room 100 Northampton, MA 01060 phone 413-587.1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address y �` 0 fZe,c� Ple# D L- Q Q� L.AN Ir, Q- Mdp. .1 1 S�. Al 0 1_T,44N4 P T6 N O�� Y i7 str�cfi SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pf tc -+ ame(Print) /'` / Current ailing Address: Telephone �./ Signatur 2.2 Authorized Agent: 'bQv),DN vq . V PchivLA r,0, $y X. Ila Al. {-lATFIELD • fvt�SS_ Name(Pr' t) Current Mailing Address: Signature Telephone SECTION 3', ESTIMATED CONSTRUCTION CO$n Item Estimated Cost(Dollars)to be Official Use only completed by ermit applicant 1. Building a is (a) Building Permit Fee .� ga 2. Electrical (b) Estimated Total Cost of -o a0 Con, ruction from 6 3. Plumbing Burilding'Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I +2 + 3 +4+ 5) %G 0 Check Number This Section For Official Use Only 48dildi-ng Permit Nu,maer: Date issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2001-0655 APPLICANT/CONTACT PERSON David Vachula ADDRESS/PHONE P O Box 112 (413)247-9459 PROPERTY LOCATION 85 WOODLAND DR MAP 35 PARCEL 295 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 50 kpeof Construction: FINISH PORTION OF BASEMENT New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/Statement or License 049846 3 sets of Plans/Plot Plan THE FLOWING LOWING 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 Commission Permit from CB Architecture Committee Signature of Buil g Offici 1 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. r , 85 WOODLAND DR BP-2001-0655 G1S#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 35-295 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0655 Project# JS-2001-1185 Est.Cost: $10400.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: David Vachula 049846 Lot Size(sq. ft.): 38942.64 Owner: JORDAN PETER A&SUSAN J Zoning: SR Applicant: David Vachula AT: 85 WOODLAND DR Applicant Address: Phone: Insurance: P O Box 112 - (413) 247-9459 N HATFIELDMA01 066-0112 ISSUED ON:11301010:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH PORTION OF BASEMENT 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 1/30/010:00:00 2532 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo