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29-132 (6) The Commonwealth of Massachusetts Department of IndustrialAccidents = 0flke of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 ��M ,�• www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information /� Please Print I.eaibi� Name it tl ill t.'t)r1:.ikT117:;3t1)iTniliVi ivah' �A�'` � en4i ;Address- U! City/ tate/7.iz�: t=Zt7 HA. Phone g: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ i am a employer with 4. ❑ I am a general contractor and i ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.XI am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working or me in any capacity. employees and have workers' g P 9. F-1 Building addition No workers,' comp insurance comp. insurance.- required.] �. } We are a corporation and its l •❑Electrical repairs or additiois j �', officers have exercised their 11 IJ Plumhin�ret)airs or additions � I am i homec•,v net doing all , ork i riiZl)t ofe�:em Lion I !�1G( 1 I IN,)�V;'ikti4� di4 .1 � �' � I � I�d7vf r l airy , i 1 4� t ) t ,, 1 o '• .. �n�� and 11!'C t� ; iMirccs fN!} orlkc Other l �.,._.-.__J 1 .apph a;u haaa .)a,. ... ,l,a.a ak .fa :Ui.,.. .,tao .:,i.. <..,.,..,.,u , a... .aau.. ,..�.i,a„J.110",a,.1b:,.,,,i.u.o..;,L C Jr ain ritr r3mplo €=rF that A providin,i work-er•i c aararnr�rrcrrti rrr r� sstra�rtc stir rrtrT�rrt lrri c F«o fielon is the tiolic r rajal job vit" irrtrrrararatrora, attach a copy of the workers' compcnsation policy declaration page (showing the policy number and expiration date". d iC}S4'K' 111 }}y1�.i.4a)T, o .riiiiiIi fl {}e irlc LAY to S l__0 00 and:or one-ycar i:i unsoni ncllt_ as ,,Fell as ciV 1 i cnalt.cs in the lt)rm of_­ STOP WORK 01WERZ;;id a linc o i' it)�S"',�,i)110;i,i ilal file 1,.)laitsi ..t= .it,..�...1 4l�a , Mt�, 'rt'4 ti ations of the [AA for insurance covcra�c vcritication. I do lreffbi°c . i¢i'1411rler°the prairov and pe milth-,gi�f prT€r4117 that the infin cation trrovitled above it tram and eorre c°to ii. t1� - iii t'.- ✓ /G.JV/ /..i./-, -. - Qj iciul use onto. Do not write in this urea, to be completed by city or town oJficiaL �l ll City or'lo«vn- i errnit/l;icense f 1 Issuing .%tithority (circle tine); 1. Board of Health 2. Building Department 3. City/'l own Clerk 4.Llectrical Inspector 5. Plumbing Inspector �1 1 6. Other i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:. T k+--4 E CAA, Ck - L S o L 6 j ;7 (cam License Number Addres Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 6jgme Q enac-7 / 30/o 3 Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'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...... ❑ 11. - Home Owner Exemption i he current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families =vvh homeowner to engage an individual for hire who does not possess a license,provided that the owner acts SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 01 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding Other[p] Brief Descn'ytion of Proposed, / Work: A 1l,'t is�n,�MGAl__ ()--AM 5/r� ��3�E1�lacl�t� i7oDrS /StD�n(� AN7� RI Cc' T�21m Alteration of existing bedroom Yes No Adding new bedroom Yes X,-No Attached Narrative Renovating unfinished basement Yes _ No Plans Attached Roll - Sheet &a. If New house and or addition to existing housing, complete the following a. Use of bui'ding : One Fami-y Two Fame y Other -- b Number of rooms in each family unit: Number of Bathrooms i c- :s there a garage attached?._ --------- d Proposed Square footage of new construction --� Dimensions I e. Number of stories? � f f. Method of heating? Firep'aces 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. 1. 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 r, �N I KI -. Q �_ l _`J �._.-------------- ------- ---------------- -- ----- as Owner of the subject property. w y hereby authorize PW&� �13 EAy to act on my behalf, in all matters relative to work authorized by this building permit application �,uc►�r Signature of ner Date j �iJF` I �'Gar.},�dec_,re F,i'dl th,- .=taie:ne nts and `nf � ��;co F } �Itt 1,.��;' v��-1} L P1v�'�'£' j { 1 and t-'e:;el # Sinned,Inner the mains Rnd Pena-ties,of periln, 1 � i i Print Nan: i �-1 T ZONING AU Information Must Be Comoieted.Permit Can Be Denied Die To Incomolete Information Proposed Required by Zoning This cojumn to be filled in by ` Building Depariment C + Lot Size � l ZS Frontage Setbacks Front q0 Side L:qO R: (o© i' L: R: Rear Lj(-) Building Height 'L©f Bid . Squar`e F000ttaee 7 SQ, % 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 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 ' rr J__ L_ and 1__ e rr1— 4FY'.(..€F..4'}t=,Y; S..�rl—!E—'rgt t4F E4.34.:1 F.F(s;"— 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 0 NO T YES..then a Northampton Storm Water Management Permit from the DPW is required_ Department use only D EECMW E ity of Northampton Status of Permit: (C ' ilding Department Curb Cut/Driveway Permit +ll 212 Main Street Sewer/Septic Availability- i MAY 2 2 2015 Room 100 Water/Well Availability ,.-,,,-,No hampton, MA 01060 Two Sets of Structural Plans ph one 413� -' 87-1240 Fax 413-587-1272 ~ PlotfSite Plans Other Specify_ I - R i--VA T OR -D E hA G IS W N R TWO F 14 i i- A U­t U. L.k.- RJJ. 1. AL CN, itt. RE ;0 SECTION I -SITE INFORMATION 7 1.1 Property Address: This section to be completed by office '?N 6 6 C'(--o e t'-\ C- Map Lot Unit (Le KL 0--c— V4 A 6`0 6 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: i CD \L\J 1 2--t fV `5 Name(Print) Current Mailing Address: Telephone Signature L/ �.2 Authoized Agent: --A qC6 AMA- <3 i f G: Pi E4.D l4- Na Print) /9 Current Mailing Address: CU dia 0 ) -- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cost(Doiiars)to be Official Use Only comp!eted by permit applicant 1 Building Iq (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, Totajz= (1 +2+3+4+ 5) Check Number This Section For Official Use Only Building Permit Nurnber: Date Issued: Signature: Building Commissioner/inspector of Buildings Date 26 GOLDEN DR BP-2015-1161 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29- 132 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: replacement windows/siding BUILDING PERMIT Permit# BP-2015-1161 Project# JS-2015-002181 Est.Cost: $14000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAMELA LEBEAU 064756 Lot Size(sq. ft.): 11325.60 Owner: KOLODZINSKI EDWIN A Zonine: Applicant: PAMELA LEBEAU AT: 26 GOLDEN DR Applicant Address: Phone: Insurance: 248 Bryant St (413) 296-4506 CHESTERFIELDMA01012 ISSUED ON.512112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 2 REPLACEMENT WINDOWS, 2 DOORS & SIDING 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: FeeType: Date Paid: Amount: Building 5/21/2015 0:00:00 $70.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner