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25C-251 (10) mgti p2, (trilit a g J af NItZ'f antpfrin r ht } Pd Sfiasanclinsetts ' `' DEPARTMENT OF BUILDDZG INSPECTIONS 212 Main Street • Municipal Building ' o Northampton, Mass. 01060 ~ ' " �` WORKER'S COMPENSATION INSURANCE A li'll)AVIT / (li censee/permi ttee) with a principal place of business/residence at: • /l 7S 1 A 'iZ /( + p. rary yv (phone #) 4 To- c.) (street /city /state/zip) do hereby certify, under the pains and penalties of perjury, that: ( am an employer providing the following workers compensation coverage for my mployees working on this job: (Insurance Company) (Policy 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: ; ,t 4. (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) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additional sheet if necessary to include information pertaining to all contractors) I am a sole proprietor and have no one working for me. ) I am a home owner performing all the work myself. NOTE: please be aware that %while homeowners who employ persons to do maintenance, =st udio° or repair work on a dwelling of not more than three units in which the homeowner resides or oa the grounds appurtenant thereto arc not generally considered to be employers under the worker's ration Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the legal status of an employer under the Wodcor's Compensation Ad I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' Office of tawrwoe for the coverage verification and that failure to secure coverage under section 25A of MOIL 152 can lead to the imposition of criminal penalties consisting of a fine of up to S1,500.00 and/or imprison of up to one year and civil penalties in the form of a Stop Wait Ouch and a fine of 5100.00 a day against tne. For dq aitn of al use eery J►.. • Permit Number Map# Lot Sit... Licensee/Permittee Ike Version!.7 Commercial Building Permit May 15, 2000 AW a 3� V p � 3 �' SEC I,ON S TRUCTURAL PE RlREV V I (7,q,P:P � Y10 4.) - Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ FSECTI NA ii pWNER AUT�HORIZAT(ON TO BE�COMPLETED 'WHE ' A OWNERS /SaENT4ORxCONTRACTOR xPP 1> S F t BUll "DING PERMITa , „ 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, SOe /a S SN 5 4 , as Owner /Authorized Agent hereby dec are 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. Toe j /1c�''A/5ir i Print Name otimik i natu of Owner/Agent Date SEC rION 12'. = '.CONSTRUCTION SE 10.1 Licensed Construction Supervisor: Not Applicable ❑ " Name of License Holder : J J S 4 U 4 , ©5 7fi ,( ' License Number //f .TS r\ 4/ G ) , 7') 4w+n i'oiL , yyt A & Alor, Address Expiration Date �,v�6v. -__ ' t-1 S 6 T t t -. G 30 --) ignature Telephone SECTION 13'' - 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 ❑ Version1.7 Commercial Building Permit May 15, 2000 %ECTION r 9 'PROFESS1ONAt ESIG °N' E ONR STUGT10tj3�+RYICE FO'i2 BULL DIN4 ,'N s O STRUCTURES SSUBJ 'CT T � a� .da � x 1 3 r +�'3±� .3 x .� r . + u� _> pn�)�} � �s � 3 � '!! CON5TRUCTION CO if kb PljR ANT, "O 780 CMR,1Y (CONTAINING r 1ORe THAf�0S, QO C F QF ENCLOSED S )kCE); 9.1 Registered Architect: Not Applicable ❑ Name (Registrant): Registration Number Address Expiration Date Signature Telephone 92 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility " Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 9.3 General Contractor t q 0 s. f"} c, i /'v CC Not Applicable ❑ Company Name: TC/ e .17)7 7 AiS4, Responsible In Charge of Construction Address /n� �l . 5 - 1 /` 01 Si ature Telephone ` <" Version!.7 Commercial Building Permit May 15, 2000 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: ublic ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑ _ 8. NORTHAMPTON ZONING 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 ! Z Bldg. Square Footage / ; % Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces (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: elk' D. Are there any proposed changes to or additions of signs intended for the property ?YES _ No) IF YES, describe size, type and location: Version!.7 Commercial Building Permit May 15, 2000 7 n a `� �? 7 3 } v 4-'4 40N 3 i Afi �Iha . - _, < _ < ' P ""f' i �, , 7 113 "51120'404 i :, $BC 74 TRtJ Tic s SLR1II ES f ® ' � C " C S THAN S;ODQ a � '14:1', F K '�� u � y. £ f ' eilli , t a9. 46YE br � 4 w ttP14"� � I ' "'``" ' r �3 ON, iul £ v ,N ma ., ; p'I n,V°ovaor_ Interior Alterations Existing Wall Signs Existing Ground Signs Additions ❑ i Roofing ❑ ❑ ❑ Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ] ❑ Access Building [ ] Repairs [.(] - DESGTP �rd'` 3 : 4"PL..�c) "t',� 4 foot" FP °J» tIJ 4 ° I 4 rr 4Ce -:-. , 741), �t < 9 3 3 l ' y 331$ 11 9: a SECTO 5 USWG ROUP AND CONSTRUCT!Q op E' , USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1.3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S -1 ❑ S -2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE TH1SS IF EXISTING BUILDING `UNDERGOING RENOVATIONS, ADDITIONS AND /OR CH_ ANG US Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SE 6 HEIGHT AND AREA -° e ems$ BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION - a r7 $ j Floor Ar per Floor (sf) 1st d TV 2nd � 1st �a 3 2nd 3 rd e � ? , 'J 7 4th . t 3>C 4 Tot Area (sf) /5 0© Total Proposed New Construction (sf)�� ��� . . ... N , e ibk _ ... Total Height (ft) - � � ' �s Total Height ft '.; , q� File # BP- 2001 -0842 APPLICANT /CONTACT PERSON Joseph Jasinski ADDRESS/PHONE 115 Island Road (413) 584 -0307 PROPERTY LOCATION FAIR ST MAP 25C PARCEL 251 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out (A SO Paid � 9 ' (A SO Tvpeof Construction: REPLACE SHED ROOF FROM WIND DAMAGE (INFIELD) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 057025 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received & Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w /ZONING BOARD OF APPEALS Received & Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w /ZONING BOARD OF APPEALS 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 Conserv.tion Commission Permit from CB Architecture Committee _ /� 4 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. FAC,R ST BP- 2001 -0842 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: shed BUILDING PERMIT Permit # BP- 2001 -0842 Project # JS- 2001 -1575 Est. Cost: $3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Joseph Jasinski 057025 Lot Size(sq. ft.1: 871200.00 Owner: HAMPSHIRE FRANKLIN & HAMPDEN Zoning: URA Applicant: Joseph Jasinski AT: FAIR ST Applicant Address: Phone: Insurance: 115 Island Road (413) 584 -0307 NORTHAMPTONMA01060 ISSUED ON: TO PERFORM THE FOLLOWING WORK: REPLACE SHED ROOF FROM WIND DAMAGE (INFIELD) POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector 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 NORTIaMPTON UPON VIOLAT N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building ./3/61/ 559 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo z / • / / / / i / / / / ,, / . , / / 4-/ / / . . , / . / , .- , / / / ... , , • / ,.• . , , . /6 / , o 0 . _ 0- t - t ..... ; 1. _Z ...., ••,.„, ,- ' „ , P..„ , , , , NNN• . ...,..., • .... . N. . \ .N.., . N• N., ‘... . ... N.... N ' • • ''.". •, \ N ... ••••.,.. N •.... , ....,,, \ . \ 6 \ ...., v ... . , / . . .. NN, .. --, \ . • / , .. . \ ... ,e...., .., 1 -,..... N....._ .... ,., --... ,........... ,. 4 ........ 'co.{ ,.." ( .... ,... 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