10B-108 (2) 20 GROVE AVE BP- 2011 -0851
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map.Bloc IOB - 108 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit# BP- 2011 -0851
Project # JS- 2011- 001403
Est. Cost: $11000.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN ZIEMINSKI 017889
Lot Size(sq. ft.): 21170.16 Owner: CHERULNIK PAUL D & BEVERLY E
Zoning: URA(100) / Applicant: JOHN ZIEMINSKI
AT. 20 GROVE AVE
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON :412912011 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD ROOF & SCREENING TO REAR DECK
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 4/29/20110:00:00 $66.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP- 2011 -0851
APPLICANT /CONTACT PERSON JOHN ZIEMINSKI
ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413) 247 -9014
PROPERTY LOCATION 20 GROVE AVE
MAP IOB PARCEL 108 001 ZONE URA(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ADD ROOF & SCREENING TO REAR DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017889
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved 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 Commission Permit DPW Storm Water Management
Demolition Delay
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 MGL 40A. Contact Office of
Planning & Development for more information.
s na
Department�se only
,
City of Northampton Status ofi Perrnl#
Building Department curb Cutlpny" ' Perr'
212 Main Street Sewe r
�Sepfic Ayallabrl�ty
e� `ZOti Room 100 WaterJV�lelt Aviadabihty '
^b .-
rthampton, MA 01060 Two Se #s of 5lructural Plans
;587 -1240 Fax 413 - 587 -1272 PlatlStte Plans �k
0� Other Specify
P d
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address
Ma Lot Unit
L L -' 3 Zone Overlay pistrict
EIm St °District CB District
SECTION:2 PRO I'ERTY'OWNERSHIP /AUTHOR.IZED AGENT
2.1 Owner of Record
14- L n1 I (< 7--c' G u
Nam Current Mailing Address:
Telephone - t V-7 J
Signature
2.2 Authorized Agent: p16
D 4 r D is C_
Name (Print) Current Mailing Address:
Signature; Telephone
SEGTIO EST,I
MATED!CO TRUCTION.COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit a22licant
1. Building (a) Bwldtng Permit Fee
2. Electrical (b) Estimated Total Cosf of
Construction from 6
3. Plumbing Building, Permit, ; Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total {1 �2 +3 +4 +5) f ��t�
Check Number
- - - :.This- Section For Official. se .Qn
Date
Building Permit Number. - issued:
Signature:
Building CommissionerllnspectoriofBuildings - '
Date
Ala&
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ft Replacement Windows Alterations) Roofing E-1 R6 tD ' Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [O]
Brief Description of Proposed
Work: i7n ;c e
Alteration of existing bedroom Yes _ No Adding new bedroom Yes X No
Attached Narrative - -_.� Renovating unfinished basement Yes X No
Plans Attached Rolls - - Sheet)
6a If New house and' Ora d.ditloru O ezistmg houS.ing, cornpiote fLhe,foilowlr A:
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 st ories?
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 13E COMPLETED .:WHEN !.
OWNERS. AGENT CONTRACTOR APPLIES FOR.BUILDING PERMIT
as Owner of the subject
Y
property
here a thorize
to a y behalf 'n a matters relative to work authorized by this building permit application.
XX
Signature of Owner Date
Ic I as1 �/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/Ag Dat
i
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
/ { This column to be filled in by
Building Department
Lot Size
Frontage
c
Setbacks Front
.
Side L _. R L ` _ R:
Rear
Building Height
Bldg. Square Footage n °' " t % 1"""""
?
..__.___J1
Open Space Footage %
(Lot area minus bldg & paved
p arking)
# of Parking S paces i• - -• -i - - -`
Fill:
(volume & Location). a
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q D ONT K NOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT_KNOW o YES 0
IF YES: enter Book £ Pager and /or Document # _
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued: 3
C. Do any signs exist on the property? YES 0 NO 0
IF YES; describe size, type and location:- �
_.` any proposed changes to or a:_ i tons o_.stgns inten -(�d; or the property ? YES Q NO Q
IF YES, describe size, type and location:
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 NO 0
IF YES, then a Northampton Storm Water Permit from the DPW is required.
SECTION 8 - CONSTRUCTION SERVICES ,
8.1 Licensed Construction Supervisor 9 Not Applicable ❑
Name of License Holder e p� r.5 f'i t ��(G
/�1 f License Number
De r Er�
Address Expiration Date
Signature Telephone �Z
9 ". Registere .NomeImprouement:Contrac'tor , , Not Applicable G
33
Company Name Regis rat tion Number
' (v 2? j2 f 1] r✓ �- f !/� �' �: 2 D P 4 z--
Address Expiratioli Dgte
Telephone 1. SECTION 10- WORKE 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::_O�vne>r BUMP, on
._ The_ current _exemption.for_ "homeoyv_ners_" was ext ended 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. CM.R 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 oeriod 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
Noffflampton r tnances, a et anti' Mate ofhlassa hose tts=Ceneral-- L•a -ws. Annotated:
Homeowner Signature
t
77ie Commonwealth of Massachusetts
Department oflndustrialAccidents
Office of Investig, ations
600 Washington Street
Boston, MA 0-
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors (Electricians /Plumbers
Applicant Information _ __ Please Print Legibly
Name ( Business / Organization / Individual): --�C4
Address: ? t J Cl C) D uP_ i D L,
City /State /Zip: II - M L`Z.. D nf1 01t Phone. #:
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
employees (full and/or part-time).* have lured the sub- contractors 6. New construction
2. F I am a sole proprietor or partner- listed on the attached sheet 7. (� Remodeling
ship and have no �loyees These sub - contractors have. .8. [] D.eniolition
working forme in .any capacity. employees and have workers'
9 - Bi
ding addition
__ _ - : � SwF QVee 2,nC
[No workers' comp. insurance `
required_]
5. We are a corporation and its 101 Electrical repairs or additions
3. [] I am aomeoyvner deinj all work -- - -- Qers�aa —1-1.� glumbmg repairs or additions
myself- [No workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required-] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required. },
"Any applicant that checks box #1 must also fill out' the section belovt showing their workers' compensation policy information.
t Homeowners who - submit this affidavit indicating they are doingall work and then. hire outside cant-actors 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 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. Lic. CG SD 6 66 `f 12 0 0 / I Expiration Date: 3 l
lob Site Addre C /Z 6v LIZ !15 1`7 A- Ci State/
tY / gyp_.
Attach a copy of the workers ' - compensation policy;declarafion page'(showing the policy number and expiration date).
Failure to secure coverage °as required under Section 25A o_f,MGL: c 152 can lead 'to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one - 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 : 1�e advised that a copy of this statement may be forwarded to the Office of
Investigations of the t)IA for insurance coverize verification
-
I do hereby_certify under thepains enaltiES o„ er"u that the in orntatton rpvid ed.abo.ve_& true.arid_correct. --
- P .fP 1.. ?Y f P —
-- -- -
Si afore: Date•.._ ..: c`/ Z 2-- /r :
Phone##: `' 1 • , t 3 : t c� _
- Gffcial use oily. Do not write iii this area, tv be completed by city or fown ojfciaL
City or Town: Permit/License #
Issuing Authority (circle one):
- I. Board of Health 2.13uild ng Department 3. City/Town Clerk 4. ElectricaL Inw ector 5. Plumbing Ins pector_
6. Other
Contact Person: Phone #:
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