25C-251 (8) ltAH
olifoisk t C.LiN of Northampton
A f -+ { .4 f B ftiaaanclinsctta Spit
DEPARTMENT OP BUILDING INSPECT IONS
212 Main Street Municipal Building
Northampton, Mass. 01060 r' `
WOR10ER'S COMTENSATION INSURANCE AFFIDAVIT
', a $
(li ccuser/permi ttce )
with a principal place of business/residence at:
`,4 S 01/00) Arit ' ?,/ ?A A 010‘0 {phone#) 5 (t /° Cl 30 2
(str ee1 Jci ty /stalc/zi p )
do hereby certify, under the pains and penalties of penury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
3 ( c,, .l / r '
—
(Instlrancc Corzpany) (Polio Number) (Expiration Date)
( ) I 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) (Insurances, Company /Polio Number) (Expiration Date)
(Name of Contractor) (Insurance CompanyiPolicv Number) (Expiration Date)
(Name of Contractor) Gnsuranc: Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaath additioml sheet ifnacc a ry to iactuhc informaaoa pertaining w all onatraeora)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE: please bc awuc that while homcowncra who employ pa-sons to marmenance. construction or repair work oa a dwelling of
not MOM than throe units in which the homeowner rrsides or on the grounds appurtenant thcctn arc not generally 000iidcrcd to bc
employers urndcr the worker's. c emp iu ico Act (GL152,ss l (5)), application by a homeowo r fora License or permit may evidence the
legal tan of an a nployor under tho Worlacea Compomation Act_
1 undarat and dart a copy of this &Eatcmmt may be forwarded to the Dcpartmm2 of 1 rs A.cridead' Off oo of iu>xuance for the
coverage verification and that Liltse to accurt coverage under soaion 25A of MOL 152 can lad to the imposition of criminal penalties
comist ng of a fmc of up to S1,500.00 and/or imprisonment of up to ace year and civil penalties in the form of a Stop Work Order and a
fuse of a day against me
For d parts caul use only
Permit Number
G - Lot
n _
M apr,
Si tine o Liven •erTniuee Late
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 30 E 3 A c744.0,5 0 7C) a (
License Number
Address Expiration Date
v�-P
- s /' o 30
gnature Telephone
Not Applicable te ' � � � .... . ❑
Company Name Registration Number
) 1c 54^ ):),c..1 rim I) e
Address Expiration Date
Telephone T ?it " 307
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 ❑ 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
SECTION 5- DE5CRUPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roo ' g ❑
Or Doors ❑
Accessory Bldg. R' Demolition❑ New Signs [ ] Decks [ ] r ( Ajl,�i ing [ ] Other [ ]
Brief Description of Proposed Work: t� j /t-1 i /11 !' it T1✓ f li 4P O &c 0 " C 4C -4Au L / 4 ` ' ' `
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes iviv ayA
Plans Attached Roll ❑ - Sheet ❑
Cifi .. t r . ,,, .. l ca t did `ot ' i 'it .Acomjpi t #ta o'ii h1gr
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
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, :10€ 7 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.
_ _rue S ?JA/5 -c'
Print Name S 7;-er.„„........ A'
ure er /Agent Date 6 —6 -o
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 YES, describe size, type and location:
•
City of Northampton
) 6 - Building Department
.)‘ \\‘
212 Main Street
\\\ „ - Room 100
Northampton, MA 01060
„
2""" ' ••,^
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This'sertidivtia4e 169,mplrnp1;1,11Y'lfite'
1.1 Property
it ,4
,Zofle ' -PArftEdy/D1*.:tript •
Epi St.Dttrt. BDlstrkt
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
3
P fs.(r/ "loi
Name (Print) Current Mailing Addrev;
(4/ ? ei 3 7 . /
Telephone
Signature
2.2 Authorized Agent:
,/[ ;,) r a Name (Print) (Print) Current Mailing Address:
5 7 3 a
Sig ature 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
tiT/c/I-
/09
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Perntit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
54 FAIR ST - FAIRGROUNDS BP-2000-1116
GIS #: COMMONWEALTH OF MASSACHUSETTS
a :Bl 25C - 251 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: demolition BUILDING PERMIT
Permit # BP-2000-1116
Project # JS- 2000 -1988
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Joseph Jasinski 057025
Lot Size(sq. ft.): 871 200.00 Owner: HAMPSHIRE FRANKLIN & HAMPDEN
Zoning: URA Applicant: Joseph Jasinski
AT: 54 FAIR ST - FAIRGROUNDS
Applicant Address: Phone: Insurance:
115 Island Road (413) 584 -0307
NORTHAMPTON MA01 ISSUED ON :6/12/00 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REMOVE 30 X 50 SHED ROOF & 40 X 140
CANOPY DAMAGED BY STOREM - INFIELD PARA MUTUAL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
spector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
ding 6/12/00 0:00:00 502 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo