333 Acrebrook deniedCity of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
Department use only
Status of Permit:
Curb Cut/Driveway Permit _______ _
Sewer/Septic Availability _______ _
Water/Well Availability ________ _
Two Sets of Structural Plans ______ _
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ____ _
Other Specify
SECTION 1 • SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map ______ Lot _______ Unit __ _
333 Acrebrook Drive Zone ______ Overlay District _____ _
----------------------E~lm St District ______ CB District _____ _
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Vitaly Dzheri-zherukha
2.2 Authorized Agent:
Vitaly Dzhenzherukha
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
130 South Park Terrace, Agawam, MA 01001
Current Mailing Address: 203449_5809
Telephone
Vitaly Dzhenzherukha
Current Mailing Address:
Vitaly Dzhenzherukha
Telephone
Official Use Only
(a) Building Permit Fee
(b) Estimated Total Cost of
Construction from 6
Building Permit Fee
Check Number
Section For Official Use Onl
Building Permit Number: ___________ _
Building Commissioner/Inspector of Buildings Date
@
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Uh\.9r~ va\,oo . &'IV\
SECTION 8 -CONSTRUCTION SERVICES I
8.1 Licensed Construction Su~ervisor: Not Applicable D
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home lm~rovement Contractor: Not Applicable D
~~\; 0-Z~hwlz..Y\e(\)~ ~i:+3~:1
Com an N e Registration Number
l'3D Jl)~ ~~ 1Crvac.e. 3 \3ohq
Address Expiration Date
~C!~J Qf/"'\I IV\ Ir 6 l <1::) \ Telephone ~3-y~-S"i'()~
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152, § 25C(6)) I
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 builqing permit.
Signed Affidavit Attached Yes ....... rs/ No ...... D
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor ("HIC").
M.G.L. Chapter 142A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units .... or to structures which are adjacent to such residence or building" be
done by registered contractors.
Note: I/the homeowner has contracted with a corporation or LLC, that entity must be registered.
Type of Work: t,WA d:la1{b rewwJ I rzM d,s·1div'GL Est. Cost: tg QlJ\)
'l~ed ·'
AddressofWork: 3?>3 ktebwt. Oo'Vf., J\Q~ 11MA
Date of Permit Application: __ 4_..j_l 1_._._Jl~f=--------------------
1 hereby certify that:
Registration is not required for the following reason(s):
_ Work excluded by law (explain): ____________________ _
Job under $1,000.00
\/ Owner obtaining own permit (explain): __________________ _
__ Building not owner-occupied
_ Other (specify): _________________________ _
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HA VE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L. Chapter 142A. SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contn~or Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above
/l1/t '(
Date
I
~ The Commonwealth of Massachusetts
1 Congress Street, Suite 100
Boston, MA 02114-2017
~ , www.mass.gov/dia •
Department of Industrial Accidents
Woi·kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lee;ibly
Name (Business/Organization/Individual): \l \~~ Ot. hl'.h7 }Jfb.)~q
Address: \3b S)U\ rao-:~
City/State/Zip: O\C50
Are you an employer? Check the appropriate box:
1.0 I am a employer with ____ employees (full and/or part-time).*
2.0 I am a sole proprietor or partnership and have no employees working for me in
_rny capacity. [No workers' comp. insurance required.)
3.l.3ll I am a homeowner doing all work myself. [No workers' comp. insurance required.) t
4. DI am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers' comp. insurance.t 6.o We are a corporation and its officers have exercised their right of exemption per MGL c.
152, § I (4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. D few construction
8. LI(Remodeling
9. D Demolition
IO D Building addition
11 .~lectrical repairs or additions
12.~lumbing repairs or additions
13 .@.oof repairs
14.00ther _______ _
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tcontractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _____________________________________ _
Policy# or Self-ins. Lie.#: ___________________ Expiration Date: ________ _
Job Site Address: City/State/Zip: _________ _
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1 ,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
ldohereby ~pa·
Signature: ~
perjury that the information provided above is true and correct
Date: Cf/t'f /I JJ
Official use only. Do not write in this area, to be completed by city or town official
City or Town: _________________ Permit/License# _______________ _
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ---------------
Contact Person: ___________________ Phone#: ______________ _
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 1 SOA.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
Or will be disposed of in a dumpster onsite rented or leased from:
Signat~rDate -----
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.