46-037 (3) 178 ISLAND RD BP-2020-1033
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:46-037 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2020-1033
Proiect# JS-2020-001745
Est.Cost: $10000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 7143.84 Owner. SIEAKOWSKI JOHN
Zoning: Applicant. SIEAKOWSKI JOHN
AT. 178 ISLAND RD
Applicant Address: Phone: Insurance:
178 ISLAND (347) 263-0831-()
NORTHAMPTON MAO 1060 ISSUED ON:3/16/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE EXISTING ROOF AND RESHINGLE
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 3/16/2020 0:00:00 $40.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
f...
212 Main Street Sewerlseptic Availability
Room 100 Water/Well Availability
. � Northampton, MA 01060 ` -�, ;;$1fucturaf Plans
phone 413-587-1240 Fax 413-587-1127 E_ lat sits O ad9-
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVA E IVIPOS UNE JDR TWO FAMILY DWELLING
i
i
SECTION 1 -SITE INFORMATION oE"T OF cun.�!r;r, c ��
- _ "_'TMist• e�ti6m to
1.1 Property Address: be gompll ted by office
___,_� �._.._
Map Lot Unit
178 Island Rd, Northampton MAO 1060 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
John Sieakowski & Sofia Szamosi 178 Island Rd, Northampton MA 01060
Name(Print) Current Mailing Address:
347 263 0837
Telephone
Signature
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
completed by permit applicant
1. Building $5000-510000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) *10
5. Fire Protection
6. Total=0 +2+ 3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: O— aQ rQj 15 Date
• Issued:
LLA
Signature: 3 (o%Q
10
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ✓❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (Q Siding[0] Other[�
Brief Description of Proposed 7�
Work: R�-'MOgIE rYW-T(vi C. -R03t�r'ZS�►�1GLF
Alteration of existing bedroom Yes No No Adding new bedroom Yes No No
Attached Narrative Renovating unfinished basement Yes No No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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. 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 .
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
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, , 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.
John Sierakowski&Sofia Szamosi Print Name
03/16/20
_Signature of Owner/Agent - CV Date
City of Northampton
Massachusetts _
�f DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building w
Northampton, MA 01060 ,EJ1,
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:If the homeowner has contracted with a corporation or LLC, that entity must be registered
Type of Work: Est. Cost:
Address of Work:
Date of Permit Application:
I 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 HAVE 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 Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above
property:
Date-3/16/20 Owner Name and Signature John Sierakowski&Sofia Szamosi
Z
-
�� --
City of Northampton
Massachusetts
� Y
DEPARTMENT OF BUILDING INSPECTIONS
, f 212 Main Street •Municipal Building
Northampton, MA 01060 srpy �.
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 150A.
The debris from construction work being performed at:
178 island Rd, Northampton MA 01060
(Please print house number and street name)
Is to be disposed of at:
Valley Recycling 234 Easthampton Rd, Northampton, MA 01060
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date _-
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.
The Commonwealth of Massachusetts
x Department of Industrial Accidents
A I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Lezibly
Name (Business/Organization/Individual):
Address: M
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
Ta pe of'project(required):
1.[]I am a employer with employees(full and/or part-time).* ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in ti. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.W I am a homeowner doingall work myselfrequired.]
1 ❑Demolition
y [No workers'comp.insurance required.]'
I 0 E]Building addition
4.❑I 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 11.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.*
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,$1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I 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.
Contractors 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 subcontractors 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.Lic.#: 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.
I do hereby certify under thepains and penalties ofperjury that the information provided above is true and correct.
Signature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town offieiaL
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#: