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25A-133 (2) 1/Nee ' •otfxrnonll'ealtft ofiWassarchusetts q } � r `• D'c °var trnent of .Cndrrstrial �%ccicferaes� ��11d flhY Lof/JYe °4?v"Al4s flOAt - :. = 600 JTashington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit o /'111311Qi431Lr 1 ?s3:.. I»:i. •:2) �} /� /' r• e�.�y..jyq .ary ....v,.., 11 � -- I<:1!�iLU �/�/ r � '�1�.�"�- '�?r,. �5�... .f:,�U•'�.,."`:a 'Y+`:��''�.°c� na e:` it 1! i ) /'i �� v`t locat nn t �? fy'� k o I am a homeowner performing all work myself. o I am a sole proprietor and have no one working in any capacity £- Vii'..`. a ..�., i. '?= 5 - lG ..4 ' 7 -- ..:�. ' . :mci.:l / x :y. +.� � ° r• 't:.'rR , 1 ._. .:Ct �t!s.�.:' !'r:+..wY.Yv .h,.»�r?�. �' aa.'". - .- ..' •!`:'�3°i'...�..ri•:�:��4A3,:' f I am an employer providing workers' compensation for my employees working on this job. cnmpas?s rte: \4 r f't 1 a 4. '? j:1' f nddr 1 iIIIR�1 ) . . r� y, CI i _ - ► ". a• : d ,... :.hone #• �7 Murance co t'1i `-+ ..«1 -tom V E i po[iCp # t c ..> Q . .ev.'v`�a:Jf sm:eG:.nrc,5s �%8•*>e`; J 1".." ". c._•" nl � +"�.:�&.:.caw.:5r"�= .��L'�f.�Nl alb.-" �a= �k=. t' r'' r.?' F. L�' s•t�5"r'�- 3�5�'•� 0 1 am a sole. proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation polices: company name: address: ciri: in uran e i >l�- e•�.. =:_� r-a3??'«'un - . ; , �_ -? Yip :..«:.*.T+af3'.w.Y:R+w.<,w..vs: r.��C:'S':+,`SY.:�I�aY�' 1 , 7 5'. h' ftL1i' YSL':'. 3+:.,''" i' o"'. 7F !?:.j..+`P"'...a?wzr•.,..�:.c.A otnpanynattte : .. .,;::•;; ... .... .. " Address :. itv : . r n e #. ttHC ji dl • an& ee tyi;tteC r a sr' - '� a + '�" ' sT 5 w- s:• r N. o-•; Failure to secure coverage as required under Section 25A of MGL 152 ean"lead to the Imposition of criminal penalties of a line up to S1,SOD.00 and /or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Once of Investigations of the DIA for coverage verification. 1 do hereby certif� der She pains and penalties of perjury that the information provided above is true and correct. t 1 a Signature _ Date Print name t —.f1 &g i —� y Phone # 7 7 '16'?-0 r. official use only do not write in this area to be completed by city or town orrtcial Yi city or town: permit/license []Building Department QLicensing Board 0 check if immediate response is required Selectmen's Otlice { contact person- []Health Department phone 0; r}Other (rrned 3195 PIA) SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder : A ! k ��u � � T \ l y 5 7 5V1 , _ 1 License Number P . a .©Y- 7 ,6'5 D.o©ti► JeQ tom. Q ���.. ) Addre Expiration ()al te . ,� 1,` `7 K(, `7 - Ll Signa ure Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name n Registration Number , 16.6 pkfotkikUrrYtt—fh Address Expiration Date Telephone ?lLi ` 1 -1W1tD 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 buildin it. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption 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 gill 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) 1 Roofing I I Or Doors l] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[J Siding [0] Other [ Brief Description of Proposed Work: _ ta A kis) - (cQ ' - Alteration of existing bedroom Yes r No , Adding new bedroom Yes ✓ No Attached Narrative novating unfinished basement Yes r No Plans Attached Roll - Sheet 6a. If New house and or addition existing housing, complete the following: 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. Masscheck 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 S ?''1 k h - , as Owner of the subject property l hereby authorize vt ( / ' f ` .1 to act on my , i. - I matters rel- 've to work authorized by this building permit application. ? : '2 , ti Z a Signature o • er Date 1 Or 1 _. V a_ , as Owner /Authorized Agent hereby declare that th- statements and information on the for going application are true and • ate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name 1 11 11b Asolliilift Signature . • A Agent t Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. .. Department use only R EC „„u ' f City of Northampton Status of Permit: 1 Budding Department Curb Cut/Driveway Permit j - 4 2012 212 Main Street Sewer /Septic Availability �" Room 100 Water/Well Availability L_._... ._ Northampton, MA 01060 Two Sets of Structural Plans DEPT. OF BULL ,. NORTHAMF : �A o 413 - 587 -1240 Fax 413- 587 -1272 Plot/Site Plans Other Specify 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 completed by office c\ �j � Map Lot Unit ■n 1 4 D 1 Pi I O ` tC.� S Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ��,,00 Pliocl L A Ae5corll,at 7 p ` - It'O -�x>< / \ Name (Print) Current Mailing Ad : ' Telephone � Z G. 7 I aq Signature et e? 2.2 Authorized Agent: P ALI1 K iA ! ©•'x Z6 d / 4 4 f Ot,3 Name (Print) Current Mailing Address: a //.014 1 • • Ali5 ?7y ... y, Signature / Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS I 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 Construction from (6) 3. fkurnbine,-- ,el/ f 6 Building Permit Fee 4. Mechanica ( AC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number i y *CS This Section For Official Use Only Date Building Permit Number: Issued: Signatur /Z■ v m Building Commissioner /Inspector of Buildings Date 397 PROSPECT ST BP- 2012 -1072 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 133 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: chimney rebuild BUILDING PERMIT Permit # BP- 2012 -1072 Project # JS- 2012- 001851 Est. Cost: $4145.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL KORPITA 25671 Lot Size(sq. ft.): 22694.76 Owner: WILBUR C KEITH & SARAH WILBUR C/O MARK E ARSENAULT Zoning: URA(100)/ Applicant: PAUL KORPITA AT: 397 PROSPECT ST Applicant Address: Phone: Insurance: P 0 BOX 263 (413) 774 -4640 Workers Compensation DEERFIELDMA01342 ISSUED ON:6/6/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REBUILD CHIMNEY TO ROOF 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: FeeType: Date Paid: Amount: Building 6/6/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner