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17A-300 Department of Industrial Accident • s _ _aw6 --•-• • v .Z r.t tz.).1aC7/11SettS 1 imi=muir tr. 11110111111MIS :479,1r4 ' ill MHO Elfill i Office of Investigations 't, :Mr" 1 9 600 Washinaton Street 4 sem r war ii a Boston, MA 02111 1 1/4 7 F .' ,•44 ' www.rnass.gov/dia 1. - Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly _-- , Name (Business/Organiz ation/Inclividualy --/ C/ri‘i // 2/6-7(--f/A....),57C7 71 L7? 9 6Z>u Address: R & or) (24 p 6 t- Ci /(.' . • City/State/Zip: //76-c T- '/ 0 / .0 .? , S 7 Phone #: c- ( I/3 ; r Are you an employer? Check the appropriate box: Type of project (required): 1 1. 50 I am a employer with / 4. 0 I am a general contractor and I 6. ii N employees (full and/or part-time).* New construction have hired the sub-contractors listed on the attached sheet 7. El Remodelinz, 2. E] I am a sole proprietor or partner- These sub-contractors have ship slid have no. t-9 8. 0 Demolition employees and have workers' working for me in any capacity. 9 E Building addition _ comp. insuranre-. [No workers' comp. insurance required] 5. El We are a corporation and its 10.0 Electrical repairs or additions ofkershavercised_their______ _1-1.0-Plumbing repairs or additions • 3. 0 I am a-homeowner-doing-all---worl& right of exemption per MGL myself. [No workers' comp. 12.[j Roof repairs insurance required.] t C. 152, §1(4), and we have no 0 employees. [No workers' 13. Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below 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 sub-contractors have employees, they must provide their workers comp. policy numb= lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information Insurance Company NanoTe: /7 L- - 'Co ‘/E-- _.,72iNiS - C-6 • Policy # or Self-Ms. Lic. #: 5 oc) 9e)( ,xe) /f Expiration Date: Job Site Address: / 3 C - iS 71 - 4 -" 6---3 1 = z'f<'-' 1- c---- City/State/Zip: " 7-4— % --43 6 - Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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 ate of up to $250.00 a day against the violator. /5e advised that a copy of this statement may be forwarded to the Office of Investiaations of the DIA for insurance coveraze verification_ - - I do hereby certify under the pains and penalties of perjury that the information provided _above_is_true andcorrect._ Si s attire: 11111.1 IPA • Date: 1 / 7 ( Phone #: q / 3 - z (2- ; /? Official use only. Do n� wrife this az 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 #: , i ■ • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ �_j " 2 /ma /,• -- / c/ - Name of License Holder : License Number g 41)04 6 6 C / F /, ©t7e 9 Addr e N,,,,,,(Q__z„.„___1 ss Expiration Date `t — 7 3/9-6 ce Signatur Telephone 2/2 T7/2_ 9.'Registered: Home: Improveiiient.Contractor .0 .. , i,.a u , ..: ,,_; Not Applicable ❑ ...14> (6--3 4 , Zt�-y- r itestI /co Company Name Registration Number 1 4.v �o cc c C- G/41/2_ Address Expiration Date l" 1'7 Fr ErZ o y`` /1-- Telephone / 1 3/ 2 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 Jac_ No ❑ . Hdme Owner E empt1u 11 ri. - - - __ . _The_curr --ent- exemption for_`ltomeoers "was extended to include Owner 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 1083.5.1. Definition of Homeowner: Person (s) who own a parcel Orland 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 o amp on r finances; -- a e an • ,, .o . � - o ; . . -hnsettsfiener- alvLaws- Annotated. Homeowner Signature t . s 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 ? s _ ;, c f. 7. . Frontage _. Z � _. __.._... Setbacks Front ;: p "' Side L. __ R: _ L 3/ ..€ R ... _ Rear ` ? --- Building Height L Bldg. Square Footage ` % G Z Y1 ! 7 ` a- %° Open Space Footage (Lot area minus bldg & paved iiy29: /G.lJcY O parking) # of Parking Spaces ` 3 ! fv - Fill: A/0 iv C (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 e) DONT KNOW 0 YES 0 IF YES: enter Book Page 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 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location f --- -' D Are there any propose changes o or a. 'Mons .o signs intena_ea"fTTTtfeproporty ? YES 0 NO IF YES, describe size, type and location: 1 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ® Addition [] Replacement Windows Alteration(s) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [[] Siding [p] Other [CI] Brief Description of Proposed Work: - tQ"5Pu + e f L Sr292 /,4.-r e' bcZt ,4,,ecii' ( Alteration of existing bedroom Yes No Adding new bedroom _ Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll sa, If.New hodse and, Oe addi "tion to existinq.hoas nq, complete the:,followinq: a. Use of building : One Family :ve Two Family Other b. Number of rooms in each family unit: 7 Number of Bathrooms 3 c. Is there a garage attached? d. Proposed Square footage of new construction. s 5-2— Dimensions ' fL" De e. Number of stories? f. Method of heating? Cn - / 71O, 2 Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 4 - ' 4 ' 04 ' r7f C i . Is construction within 100 ft. of wetlands? Yes 7( No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade 5 k. Will building conform to the Building and Zoning regulations? - Yes No . I. Septic Tank City Sewer X Private well City water Supply SECTION Ta - 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 0 /7b /7 % s Owns Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the es of my knowledge and belief. Signed under the pains and penalties of perjury. `✓ /7- �_ / "J5( Print Name / % f Signat re Owner /Agent Date i **** . ......,..,... i.ft. r., ,.._ ...... . I . , t - I . ; 4.....„,„. ''.......... ... W k Dep tne0:0#' only City of Northampton Statuso1Permit i'i" k 4 k 4 iY a $. m h d E< •,‘ +` Building Departm urf ut,I.Ay, y Fean►t!' :4 <,, ' 212 Main Street Sewer /Septte/6atlabilkty 'r Room 100 A A t : ei k1, • rt pton, MA 01060 Two. Sdt of~Structural P��ans « ph a ,., 87 -1240 Fax 413- 587 -1272 ' PIotlS't Plans i t�' t �" k ' i o-t S peci f y i i AP • .• -` 0 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION -'SITE INFORMATION 1.1 Property Address: This section to be completed by office 35 /7 L- c,,�L -3,- ,e. M � 7 L ot Unit t 'Z -L)l t` ..->/9- O/6 6 Z ;Zone Overlay District "EI[tt,5 District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 4 - e, ( / E - - r / ' ` r S t C / c � " 4.-)e-) e , 6 , e-r p 6 E - c,,e . /7 c� e /may Name (Print) Current Mail Address: E I - Y(3 5'7 C)/ Telephone Signature 1 2.2 Authorized Agent: 5 ', cg ,4-s » q-g.:,-' 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 (a) Building Permit Fee . 2. Electrical (b E stimated -Total Cost of i,2- e e O Con frorn:_(6) 3. Plumbing Igo d Building Permit Fee 4. Mechanical (HVAC) r Z re a 5. Fire Protection - - cS 6 '- 6. Total = (1 +2 + 3 + 4 + 5) J.5 d `) e ' Check Number ^ j� / — .... .. . . This Section Fo oftl iai.Use Only_ Building Permit Number. sued: Signature: Building Commissioner /Inspector of Date File # BP- 2012 -0249 26 r' ‘ APPLICANT /CONTACT PERSON JOHN ZIEMINSKI 4 to J ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413) 247 -9014 � j �� 1J PROPERTY LOCATION 135 HILLCREST DR C ?tie' �� 'C ` - - 1 MAP 17A PARCEL 300 001 ZONE URA(100)/ j ��� E 'LN THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid k/99 k/99 #/3 G ✓f Typeof Construction: CONSTRUCT 2 STORY SFH W/DECK,PORCH & ATT GARAGE 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 INy,ORMATION PRESENTED: V 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 7- • Delay 9Y' - 77 _.". e ,--' 7-C r ------- Si, • re of Building Of cial 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. t 135 HILLCREST DR BP -2012 -0249 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 300 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: New Single Family House BUILDING PERMIT Permit # BP- 2012 -0249 Project # JS- 2012- 000392 Est. Cost: $250000.00 Fee: $1076.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq. ft.): 21867.12 Owner: JOHN ZIEMINSKI Zoning: URA(100)/ Applicant: JOHN ZIEMINSKI AT: 135 HILLCREST DR Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247 -9014 Workers Compensation HATFIELDMA01038 ISSUED ON:9/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 2 STORY SFH W /DECK,PORCH & ATT GARAGE 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: 9/50/ "6°?("e' 212 Main Street, hone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner __ .,MENNO■Nnimimm..1.1ffilialIMM=0..ft,... ..... 1 •MMOi■iMINIms.,.mm elo . 10MIMIIMIII 1 .,„ \ ( 1 4/ ----. I . , A O P 1 H, I ci v ,,,,,