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25C-251 (9)
• 1 0 .c 1 VJ-f p R., �` �?E Cr rf of l�nrfllii111�Jf011 ) _* • it ► � ° ' E lasanchncrl(e • Q DEPARTMENT OP BUILDING INSPECTIONS — W 212 Main Street ' Municipal Building Northampton, Mass. 01060 `r. WORKER'S COMPENSATION CNSURANCIL AFFIDAVIT I, _e__� ')- 51'15 I — — (lic uscc/permittcc) with a principal place of business/residence at: f iJ i kot i kom p7oita (fr A 01 t' 1 d (phone :) 51 1° 0 3 0 7 (sa ty /staicJzi p ) do hereby certify, under the pains and penalties of perjury, i.hal ( ) I : m an employer providing the hollowing worker's colnoensa,ion cove. for In\ ewplovees worl3ng on this job. f. 3c v 7 j 4'P (Insur,:no Comp: • (Policy Nurnbcr) (i pinrion Date) . ( ) I am a sole proprietor, general contractor or homeowner (circie one) and have hired the contractors listed below who have the following worker's compensation policies: (Name of Cont actor) (Insuranc Company/Pond Numbzt) - xai;auon Datc) (Name of Contractor) -- (Insurance ComDanyiPolicy Num6u) ("E:xoi radon Date) (Name of Contractor) (Ins.lranc Comparay/Pol;cy Numbel) (Expicadoa Date) (Name of Contractor) (Insurance Company/Policy Numbr) (Expiration Data) (mach 3ddi :ccz1 c'k-,ct if ❑ccci.ry to inc),u& iaforIn..aoo pcztainin€ to all ooa -con) ( ) 1 am a sole proprietor and have no one worlang for me. ( ) 1 am.a home owner performing all the work myself. NOTE: pl-.sc be •c (Le. w1 )c bcaxouv=ra ,riao emp pciooi w dp r c , .rr cL:.,' c i,,uu work on r d..db-W, of not most th n Lane tmi'u in wfoch the lwrmrnrvcr rcvdes or co the croundd zppurtcn:r..: tbcCo :..-c oo( Cn= -:11y occridacd to be c: loyco w4c the v. k e3 ccoaption Att (GL152_5,11(5)), appti .lion try n ho uco" fcr : bc- or perron rr..4 y nVdooc the log-1 ctnt.< of cn coloyer uodcr dao Wok Compm>ll.ioo Act 1 uudc:t-..d dox a copy of thi, a3lcmcm co-Ay bo fo.- wnrdod to tbo Deputaw,i of Lo futr Arena. -ri Off oo of lrxrriooe for t ° coverage vctif ziioo and th_t L•iltsc to tcaarc coverage under soctioa 25A of 1.MOL 152 can Iced to the i.^rposi io❑ of criminal pc 0000iszmg of a frac of up to 51 .500.00 arado- inapri oorncnt of up to ouc year nod civil pmaltio in the form of n Stop Work Order nod a f m o(S 100 -00 . t y . gtinA tnc For dcp.rtnnr.31 u.c only Pc-cult Number ____ ir Ma Lot y !gnatu - f LiccnsccfPcnniucc I )ate SECTION; 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ti J4 5 /Ai. . 0 5 ?& ? f License Number l/C ! /1/o IA 1 ,44 l i A,.," l 0 Address Expiration Date es, ", i y.;:::w 4j ;„1, yti-O 7 gnature Telephone A Not Applicable ❑ II Coipany Name Registration Number I'f_ 5 / Nl a r -r,h, ,lam OM 6 4 G k Address Expiration Date Telephone r? 1 / 6 307 SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑ �v_ P a 2M f v" 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- DESCRIPTION OF PROPOSED WORK. (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. )0( Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: [ ., , f2 S[ 1 U17l to �A. l f p/161 44) fe t Alteration of existing bedroom Yes d it Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet ❑ . � cif. dctiti a xi F lg *¢t tn coi 1ple e e folio/Wig: 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 , 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, JUe . TT/ 5 </VS , 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. �Ge 1- A5 2-Ais 4 Print Name Signature of Owner /Agent (-j.o Date 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: ,� E ,. 6 2 9Q� pity of Northampton \ \\1 , - ,% \\ s v1� uilding Department \\\:1: — r ,� 212 Main Street `'�� v.........„"" ` ` Room 100 _ wn Northampton, MA 01060 -, . phone 413 - 587.1240 F ax 413 - 587 -1272 � � � `��' APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address: fi his sectlott t I s C ampletedb +l#. #Ie P Y t" r ', i t "t .-1, OA P t)a Map Eta , f it M , Ai{i t,. r o /} .7 0 ,/ "l t -4 alai(' ©rle . . Or ppstrii EIm Si District ., CEt flir>lt SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address t!;' 2 / 0 0 7 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Est Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a(b) ) Bu Permit Fee i`Lt?G4 c" oc 2. Electrical Estimated T of 3. Plumbing Construction otal from (6)' Bu ilding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number Th $ e ction I or Of #icia Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/ inspector of Buildings Date 54 FAIR ST - FAIRGROUNDS BP-2000-1117 GIS #: COMMONWEALTH OF MASSACHUSETTS ;ap :Block: 25C - 251 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: roofing BUILDING PERMIT Permit # BP-2000-1117 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 NORTHAMPTONMA01060 ISSUED ON :6/12/00 0 :00 :00 TO PERFORM THE FOLLOWING WORK: STRIP & REPLACE WIND DAMAGE ROOF - INFIELD PARA MUTUAL OST THIS CARD SO IT IS VISIBLE FROM THE STREET .ispector 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: uilding 6/12/00 0:00:00 502 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo