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�. . u . =— DEPARTMENT OF BUILDING INSPECTIONS
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212 Main Street • Municipal Building
Northampton, Mass. 01060 .'" No s''
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
I, 5+2..., fi, 2,,,./„ i3O 4
(licensee/permittee)
with a principal place of business/residence at:
'T Cit-c a'-. ' al- (phone #) 9 y -3F -) '
(street/city /state/zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) 1 am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Compaly/Policy Number) (Expiration Date)
t.
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional sheet if necessary to include information pertaining to all contractors)
,4 I am a sole proprietor and have no one w orking for me.
( ) I am a home owner performing all the work myself.
NOTE: please be aware that whirs homeowners who employ persons to do maintenance, construdion or repair work on a dwelling of
not mote than throe units in which the homeowner resides or on the grounds appurtenant thereto arc oat generally considered to be
employers under the worker's compassatioa Act (GL152.s 1(5)), application by a homeowner fora license a permit may evidence the
legal status of an employer under the Waimea Compensation Act
I understand that a copy of thin riatcmcnt may bo forwarded to tbo Dtpartmml of Industrial Accidents' Offioo of rawnnoa for the
coverage verification and that failure to sxitre coverago under section 25A of M(1L 152 can lead to the imposition of criminal penalties
consisting of a fine of up to S1,500.00 androe imprisocuricrd of up to one year and civil penalties in the form of a Stop Work Order and a
find of 5100.00 a day against me.
For departmental use only
'. Permit Number
4 t , Vt Map# Lot #
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SECTION 8-- .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �� � t� \�11� ® � 1354,
License Number
- 7o 6/ us�. R AJ Mr °1ff fl V3i/o3
Addr- fi - Expiration ate
T r
.�I � 1 L _3
Si: ature Telephone
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r e� f ,; , ; ' Not Applicable ❑
`L0.L Qh ZJ =c r't h�o ivoicici
Company Name /� Registration Number
`"70 a�!n r PC /ir0`
Address Expiration Date
11 A Telephone - - 3 S 7
SECTION10- 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 'i( No ❑
The current exemption for "homeowners" was extended 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. CMR 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 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
GTION 'i ;V Jo l ® PR®POSEDVOR, ch c ao olicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: It' cc - 1 i h fi i . C.., , 1 d C-0‘ fifer s w e u✓
Alteration of existing bedroom Yes +4 No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Rollt>l - Sheet 0
Ga�If Ne 1id ; ddition tae i'sting ho sing; �complefe t ' lfol in :
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. Mascheck 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
S,ECT,ION 7ktOWNE.,tAUHOR(ZATION ` TO.BE COMPLETED'. WHEN
OW NERS a AGEI"VT OR db TRACTOR APPLIES -rOR. BUILDING PERMIT
I, F �csr fy kIewk.rk , as Owner of the subject property
hereby authorize 5& i t.+-% � 2 & �O to act on
my behalf, in all matters relative to wor uth`ri d by this building permit application.
/4 t2i ,2 ea 2
Signature of Owner Date
1, 5teveh ti. 2.JCL.L,1, , 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.
5f le.QA-. vcJ- ,
Print Name
' ti
Si: a ure of Owner /Ai t D to
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES _
No
IF'Y�S, desbribe size, type and location:
• .f Northampton
E E - 7 t „r. • i g Department
Main Street
11 loom 100
I 1 L mo } - olvorj a , pton, MA 01060
phone 413 -587- + 240 Fax 413- 587 -1272 �
C � r
7 t-Pt nF q�f�l_Ulfll (r7 -', F iIC,NJ � 1
t- - --AF RLIcAl- tE)N -T -CfONSTRUCt, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This sectio r #o , e male
Map �t lXSIII.
L/ f /� Zone L ® rla ®istr c
IVOY �tw *�,IpiJ'1 ri H t
Elm r ~. BDist c t>, SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Dirt) -fy / Jevv -,w tK 3). Cfe-h s JY, 1lc:1.
Name (Print) Current Mailing Address:
. / ._ -_ .� . Telephone
Signa • re
2.2 Authorized Agent:
Sfe.Ve - I'1. �ucc, n 0 ' (Gt( 5 s\ -, Pr) . 4/ '/a
Name rint) Current Mailing Address:
r"• 5i l/ _ 3 1
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) Estimated Total Cost of
&SSO — Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) $ Check Number zO
This Section For Official Use Only
Building Permit Number: a, , —367 7 Date'Issued:
Signature;.
�Bui IdingCommiskaperinspecter of Building De �,
File # BP- 2003 -0367
APPLICANT /CONTACT PERSON Steven Zucchino
ADDRESS /PHONE 70 Gleason Road (413) 584 -3878
PROPERTY LOCATION 32 GLEASON RD
MAP 18C PARCEL 092 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 1/4..qQ 066
Typeof Construction: REPLACE KITCHEN CABINETS & COUNTERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 021356
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFWIATION 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 Co ' sion
'- , .ei'e i. d Zoo 1.--
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.
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32 GLEASON RD BP- 2003 -0367
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 092 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2003 -0367
Project# JS- 2003 -0611
Est. Cost: $8200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Steven Zucchino 021356
Lot Size(sq. ft.): 11238.48 Owner: NEWKIRK MARTI
Zoning: URB Applicant: Steven Zucchino
AT: 32 GLEASON RD
Applicant Address: Phone: Insurance:
70 Gleason Road (413) 584 -3878
NORTHAMPTONMA01060 ISSUED ON :10 /9/02 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REPLACE KITCHEN CABINETS & COUNTERS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: 1 l b /off Z6 Meter:
Footings:
Roug Rough: /rl37 /Qj.. House # Foundation:
_ 1 Driveway Final:
Final• Final: 11 (403 Rev. Rough Frame:
Gas: Fire Department Fireplace /Chimney:
i
Rough: Oil: Insulation:
Final: Smoke: Final :6 /t 1 -1 ti4d 3 -._
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA ON OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy�� � Si
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 10/9/02 0:00:00 308 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo