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36-239 (4) ,• The Conijno health ofMassaclniselfs• —» : Departnrent;of fndr striaLAcctde its • s l , Office ofrnvesfrgclftaIis £Y a 6QQ Washington Sfr it `�7_ �3 w,�vwsiuuss gov /dry: . Workers' Com pensatio n- Insurance Affi�da_vit II alders4C'o�t fr alders + Iectridait§/Plumbers A s .licant Information. Pte -ase tithe iti , . Et Name ( Business /Organizatiooticlividual): /4 ' f `' .. Address: / ,00 - w - City/State/Zip: t3' (� Vt�fl �t� j�l f�'l fl ��� ��o�ze�# : _`,� �� �` Ci �� :��� � - Are you an employer? Ch the appropr- mate:box '' d: T e y t p 0-,A0- d)�, 1. [ I am a employer with 4. Q I amgent rak contractor anal I 6• L evv ctnfs#?udiron employees (full and/or part ..time).* have Iiifeel ti M. 11 0..AT_ actpt_s „ a 2. El am a sole proprietor- orpa trier- - :list -.d a tfaclfe 7 0 .Rt "nnprTelm'g. .. ship and have no emp1o. ee Tea' © foi ave a r j ? io" f working for me in: any. capacity:.. empto es<an l4Ye -c kegs" on. G 13F_J1 - 4 [No workers' comp. insurance P' v required.] 5• Q W>uat oigor4anand x,0.02k6ff 6ra 3. ❑ I am a homeowner doing all work officers hav -ex isd tl i eit F 1;u: ] umbtrlg repairs; or'-ad'ditions: _ , 1 myself. [No workers' comp. ?li ht o Q7centpl ot1 er t o - ; c 152, 4 insurance required.] t § I(f), anti ivaie=rlo..., �--� r �� t emplo3�ees. [N2.-Whil<d s "t ] >r ,'7' t'tr` - 1r31 ;' comp: nsurancg requ ro-.(1 ' _ - r r� ` ��. 1�b s ii • *Any applicant that checks box #1 must fill out t}ieset tion,belowshow.mgttetr wQriars Op penA p � 3_olibjc3#1 ft. 4 . • Homeowners who submit this aff indicating ,they ar e dpmg all workgncl:thp r i cant 4ftlrs#rkuIC a tgAir411.AY4 nn P.E& , suety - 4; musf tContractors that check this box attached an add21 h itioneei,ti'llownrg x13411: Of the ib n ltra`�tprstrt slat ljetl;[ S Pltot~f)t g.7. 4hiiS iV; W 4.4 employees. If the sub - contractors have employees they usPprgnrdeftie1r' NbdtF,t$:*•F4tii pv1l y�ntf�,'trf e ...„P,3 N • _. I am an employer that rs prd"vtdrn"g w cvnrpen Jrariee fo:�r, riry�' ; e ogees. Tl"el' ille d, ek:rtildjoY site-' j information. Insurance Company Name: �C j / . i- Q ( /g f)a 0 om / _ E rr a tr oa ate Policy # or Self ins. Lic. #: C 7 D �J fr.Q/ Job Site Address: 5 Di Q rn o n d r G t Zip.:,Oo 1 n del • Attach a copy of the workers' compensation policy declaration page (showing the policy n umber aniL,expiration date). a arati Failure to secure coverage as required under Secttan-25 o GL c; fin t an l e a fo tote mi osrtiotl of crirtrinal penalties of:a fine up to $1,500.00 and/or one yeal`imprisonment, ,as well -_as- eiviI „p'etialtles n e f'oxm ova ST'O TQf D0ER and a'fin of up to $250.00 a day againstthe violator. Be ati sed-that a cop of tlhis stateinentma0,e'. o,fwarded; tlii Offied: f s Investigations of the DIA for insurance coverage uenfcation. 6__ - I do hereby certi der the pains and enaltles of perjury tha t r tionL ovrded abaveas frue:arit ebrre Si_nature: ._ - / /�- 'I L. _�_J►/ Date V ti Phone #: cl — / Official use only. Do not write in this area, to be completed by city or.-town offcial City or Town: Permit/Licensc # _ _ Issuing Authority (circle one): - - Inspect 1. Board of Health 2. Building Departmenf 3.._ Ctty/Toyyn Clerk 4,,T;lectrica7 Tns�r er`t„ar � p�. _ . ,� 6. Other �;, . _, Contact Person: Plfone # t ®+ ++�® ,m 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: DQv (C) l� 1 �C C — L t — T ` VJ License I S5 1 lit in • C ` iee nq A8 . 1 G • 0 130 ( Number 1131 t 3 Address 1 Expiration Date � � ' .Cd ,fQ, 413'1 - 1 2�0I C D Signat e Telephone ,L i l: x 12.2m i a i' a M = " "s Not Applicable ❑ PeLLA tP (7s> 0uc S ,1 NC. 1 2,219 Company Name Registration Number MQ ` C-�c2en N1G 0 1'O 1 ,31 .)(4 (c 2 Address Expiratiorf Date C Q»& 4 C. 1 0 1. 49- , Telephone 4 . L 7 / -i -$ 4 0 9, C 0 th � � , r e F a ,� , '' a 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 No ❑ K p 1V 2 i €� = � 11 P 4 t ,m v - � 7 / 1 , 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 • New House [J Addition El Replacement Vyj�fldows Alteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks [C] Siding [O] Other [0] Brief D scrip 'on of Propos work: � Ins l l ,r∎5 n a(e l u c� R � i � , ka P c�Ti � b IN . LQS�nci LI( i s n ' c G e n � • Alteration of existing bedroom Yes k No Adding new bedroom Yes ✓ No J n t7U - Attached Narrative Renovating unfinished basement Yes L / No /,. N b Plans Attached Roll - Sheet c he n • r�' aid I: Ai ?•er3 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 fk p I t eat t i Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floogplain 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 , nn,.... wA3: ".» "• `.. �v-ca as „e, P.w,,..v. •,.w,... E'� :'K' 9. 40'4 1Siz: I, x A a u d1 i u s , as Owner of the subject property �j hereby authorize ` 6 L r ? to act on my behalf, in all matters rel. ive ork authorized by this building permit a.plica 'on. Q L /i 3 O// Signature of Owner Date 1 JQU1 1N `"E �� ` Lc r P`2_0 11 Ve 1 J � 1 N•) , as Owner /Authorized Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ►DQ,v c� Lk i iE Print Name c. iikta, V/C Signature of Owner /Agent Date Amoniffir- , 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 i Lot Size 1 1 I 1 I I Frontage 1 I I 1 I 1 Setbacks Front 1 1 1 1 1 Side L:1 I R:1 1 L:1 1 R:I 1 1 1 I 1 Rear 1 1 I 1 1 1 Building Height I 1 1 1 1 1 Bldg. Square Footage 1 1 1% 1 1 1 1 1 1 Open Space Footage Vo I (Lot area minus bldg & paved I 1 1 1 1 1 1 1 I I parking) # of Parking Spaces 1 1 1 1 1 1 Fill: { (volume & Location) ! A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 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 ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO c IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO er 1 IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • �4. 4 5 DIAMOND CT BP- 2011 -0880 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 239 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit # BP- 2011 -0880 Project # JS- 2011- 001438 Est. Cost: $3885.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PELLA PRODUCTS, INC 091496 Lot Size(sq. ft.): 30753.36 Owner: PUGACH ALEKSANDR & LYUDMILA GORITCHENKO Zoning: SR(100) //WSP Applicant: PELLA PRODUCTS, INC AT: 5 DIAMOND CT Applicant Address: Phone: Insurance: 155 MAIN ST (413) 772 - 0153 WC GREENFIELDMA01301 ISSUED ON:4/29/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE PATIO DOOR 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 4/29/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner