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' r - DEPARTMENT OF BUILDING INSPECTIONS 4 __ _ i =
2 12 Main Street ' Municipal Building
• Northampton, Mass. 01060 ow '��
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
1 ,
(li censee/permittee)
with a principal place of business/residence at:
(phone #)
(street/ci ty /s tatehi p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's 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 Company/Policy Number) (Expiration Date)
1 f.
(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 sfxct if nccc nary to include information pertaining to ell contractors)
( ) 1 am a sole proprietor and have no one w orking for me.
_-( am a home owner performing all the work myself.
•
NOTE: please be aware that whilo homeowners who employ pcaoox to do Ira intmar r, construction or repair work on a dwelling of
not more than throe units in which the homeowner resides or on the grounds appurtenant thereto art not generally considered to be
employers undo the worker's onion Act (GL152,ss 1(5)), application by a homeowner for a license or permit may evidence the
legal status of an employer under the Worker's Coo pemation Act
I understand that a Dopy of this tatatocoast may bo forwarded to the Dcparmacas of Indcutrial Attidmte Of&oo of Imam for the
coverage verification and that failure to secure coverage under section 25A of MOIL 152 an lead to the' imposition of criminal penalties
consisting of a fine of up to S1,500.00 and/or impri3oatneat of up to ooe year and civil pemili s in the form of a Stop Work Order and a '
fin* of S100.00 a day against me.
For decortrowal wo only
• ,.. Permit Number
_1A.... r 2. ,./tid Maps# . Lot #
. YY...4 Signature of Li JPermitteer' Da e ,
•
SECTION Z CONSTRUCTION `
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
RI .r , TA ; Fri:. en 'x. n " " u � �� � Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 affia
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) famili
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner act
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(
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 " ` t)
ECTION DESCR�PTfONOFuPROPOSEDYVORK Cheak�ala o •i�cable
_ &93 _mA•NR ., vP$ a e v i '3i3'fi30H3H1k 3i,,, R .T,U.*0:7 * maw. s 2. * 4 . # r AT v ir,.,. .k?0frn " *0*0 4Y1PoN , .,n, 4 *0 04. A.. , . "',. »,
'`..s >.',r.. .'u '� *w A" e "7 „'}'k, s:3 .» t »,� ni .. Viz'. .,a:dd:;� ». "4' 'Sb9” .. ?•; "'...r ..k0 ,$' ..vv :
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: 1 1)" / IOR ' (' 405 , DD ? i /' wawa)
bedroom Yes t��
Alteration of existing ;� No Adding new bedroom Yes � No
Attached Narrative ❑ Renovating unfinished basement Yes X No
Plans Attached Roll ❑ - Sheet ❑
AfIN` front antl orZadditi:ori to existing hour'i complete the:follon ing:
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
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;ECT10N1a OWNER AUTHORIZATION - TO COMPLETED WHEN
OWNERS AGENT' O,R CONTRACTOR APPLIES BUILDING PERMIT
, as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, /+ (C/> 32- ER) 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.
7 (C c 7v, 6 . Odd 5/ (
Print Name
� _ - _ %il�.. � fr / 3 arso
Signature of Owner /. :ent 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 K 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 1
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:
Ci Northampton
u) : • g Department 0 �,, it ,,, i
1 e � Main Street i
y � F EB — 4 2002 I -N•om 100
. v'
, Nor ha pton, MA 01060
w
p oJ;,: glf' @ -- 87 240 Fax 413 587 1272 a I r
rdrr?L? "7,tr'ioN kAA �.e.Q 0- . ",ems
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be complet b -
37 / //C ST Map L
U
�� III �� 14A i � ; >.� � „
Zon :Overlay Dist � 44 r;"
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/A kG N L Z r/ 54( 3* f iti R 97 mL *Oke 4/f 6 YereY
Name (Print) .. Current Mailing Address:
:..: / ' ' 'AAC Telephone
Signature / �" (c 7
O
2.2 Authorized Agent:
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 5 3 .� (a) Building Permit Fee
7
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing � 6 Building Permit Fee
—
4. Mechanical (HVAC) \_ / /
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) (5 Check Number /f 0 `
i This Section For Official Use Only Gzik?��'"" _
p
Building Permit Number: c� / : — �
b ro.
zoo ! 3p ! sued . y
Signature:
Building Commissioner /Inspector of Buildings Date
•
1
•
3 I
I '
Curb Cut from DPW Water Availability Sewer Avai api_i.y
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
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.
File # BP- 2002 -1030
APPLICANT /CONTACT PERSON Michael Tomaszewski
ADDRESS/PHONE 34 Taylor St.
PROPERTY LOCATION 37 FAIR ST
MAP 25C PARCEL 252 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 195 10 �
Fee Paid
Typeof Construction: UPDATE INTERIOR/EXTERIOR DOORS , ADD 2ND FLOOR BATH WITHIN
EXISTING, REMODEL KITCHEN & BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOXVIATION 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
Pein it from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commi n
Li Zdi9Z'_
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requireniknts 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.
ST r; BP- 2002.1030
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: ALTERATION BUILDING PERMIT
Permit # BP- 2002 -1030
Project # JS- 2002 -1104
Est. Cost: $5800.00
Fee: $159.47 PERMISSION IS HEREBY GRANTED TO:
Const. Class: 5B Contractor: License:
Use Group: R4 Homeowner as Contractor_
Lot Size(sq. ft.): 21 170.16 Owner: Michael Tomaszewski
Zoning: URA Applicant: Michael Tomaszewski
AT: 37 FAIR ST
Applicant Address: Phone: Insurance:
34 Taylor St.
HOLYOKEMA01040 ISSUED ON:5/24/02 0:00:00
TO PERFORM THE FOLLOWING WORK: UPDATE INTERIOR /EXTERIOR DOORS , ADD
2ND FLOOR BATH WITHIN EXISTING, REMODEL KITCHEN & BATH
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 5/24/02 0:00:00 195 $159.47
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
-
File # BP- 2002 -0694
APPLICANT /CONTACT PERSO b, 1 w : WSKI MICHAEL
ADD' .5/,PHQNE34 • 1 3 111 1i' - 34 -1287 ()
1 ,,
PROPE' i < � LOCA _ 4 ' 37 FAIK''ST
MAP 25 _ 'ARCEL 252 001 ZON L s
THIS • CTIJN FOR OFFICIAL USE ONLY:
L ' !aMe 1r PPLICATION CHECKLIST
h .,. a , > , - ENCLOSED REQUIRED DATE
ZONIN 'OU`T
Fee Paid
Building Permit Filled out ��_
Fee Paid Jo x w✓
Typeof Construction: INSTALL INTERIOR/EXTERIOR REPLACEMENT DOORS, ADD 2ND FLR BATH
WITHIN EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: -4p:01 eraM c
Owner/ Statement or License
3 sets of Plans / Plot Plan L 7 1 1 1 "
--Vt4:) '11 ril '
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICE
INFORMATION PRESENTED: l
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ 642/5 / r a-Q1/11/1V
Intermediate Project: ' Site Plan AND /OR Special — '• _ 5 1 1
Major Project: Site Plan AND /OR Special
" // #/"
ZONING BOARD PERMIT REQUIRED UNDER: §
�
Finding Special Permit Varian t, 'P!...if
/ /
Received & Recorded at Registry of Deeds Proof Enclose(
1 L/
Other Permits Required: v V �%
° i 62
Curb Cut from DPW Water Availability �� 1--/S so //� i
Septic Approval Board of Health Well Water Po �J (.7
Permit from Conservation Commission Permit from
/''
Permit from Elm Street Commission
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.