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35-292 (2)
\lassachusctts - Department of Public Safet■ Board of Buiidin RC2ulatiuns and Standards Construction Supervisor License License: CS 17889 Restricted to 00 JOHN H ZIEMINSKI ;4,5,, 4, a:' 8 WOODRIDGE CIRCLE 48 HATFIELD, MA 01038 Expiration: 2/25 /2012 ( unu»issioner Tr#: 15199 '� fie - omntowevealth o � ; llamaclu,�aelk Office of Consumer Affairs & Business Regulation = HOME IMPROVEMENT CONTRACTOR l 1, Registration: 100133 Type: t /` Expiration: 6/9 /2012 DBA JOHN H. ZIEMINSKI BUILDER /CONTR. John Zieminski 8 CIRCLE DR. HATFIELD, MA 01038 Undersecretary F I The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations • r °„ 600 Washington Street • C = z Boston, MA 02111 �� wtiviv.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders /Contractors IectriciansfPlumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): fG (, / , 2 (E 1-157 Z 7 Address: b �.„, 2P r., .z / 1)4 2- x'/24= , • City /State/Zip: /./ /6 n /mss --: ru Phone #: 1 /'( -- 2 7' -- 3i . Are you an employer? Check the yP of project (required): approp t iate box: T ro 11 1. I am a emplo er with / 4. 0 I am a general contractor and I employees 49) • d/or part- time).* have hired the sub- contractors 6. 11 New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 11 Remodeling shin a,td have no a to =gees These sub - contractors have. 8. 11 Demolition • employees and`bave workers' working for me in any capacity. g 111 Building addition [No workers' comp. insurance comp: ;nsmance . required.] .. ❑ We are a corporation and its 10./1 Electrical repairs or additions off cers aye er �d them— _ _ 1 = _!I Plumbing repairs or additions 3. ❑ I am a�omeo-v�ner- deut��i- work - - - -- - -_ -- myself [No workers' comp. right of exemption per MGL 12. 1 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. • Other comp. insurance required. }. • *Any applicant that checks box #1 - -must also fill out the section below showing their workers' compensation policy info - :on. t Homeowners who submit this affidavit ; indicating they are doing all work and then: hire outside contractors must sub . a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub = contractors and state wh ther or not those entities have employees. If the sub - contractors have employees, they mist.pr•ovide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Belo is the policy and job site information. Insurance Company Name: - (-r 'c -r -. "' - ‘ j -5 - Policy # or Self-ins. Lic. #: 3 ‘ 4- o o V c ' ';/ . 26)(6) Expiration Date: 9�.�`// Job Site Address: 7 O 9 4'2 D " ( c c.- - --' r-3 .y.2 r '- City /State /Zip:" vrz: --e '!'y.- ..or 0 C Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage: as required under Se,:tion "25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a -sne of up to $250.00 a day agaLso t the violator: lie dvised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverae'e verification _ I do hereby: certify under the pains and penalties of perjury runt the information . provided _above_islrue- and.correct. Signature• -€-- z..-- L ' Date: / 21//6 • Phone #: ` / / 3 :)- 9` . 9/ y i. - Of iial ase only. Do not w in this area 4 e _. .._ t __ - c . re ff y - - ,- 'o be completed by city or town officio[ -.City or Town: i Permit/License #^ -__ Issuing 1. (circle B and of Health 2. Building Department 3. City/TownClerk 4. Electrical Inspector 5. PIumbingInspector- __ 6. Other Contact Person: Phone #: ... ' -- ' # f / / t..7.1 /1,_ ,Z, il ',., 2S 4 .w yc...i.e..Jri .4 '1 Oal 1 ' e.. /7 . . '. /.. I '," 4 / 27 // Ir7 e '' {-1'' .,,q 4 :-.V.,1; . J...., .: : 17 i?,/(7 it" Ct ' 4 0 a Ell 6 <2/ . ‘) C..4.4, ,- i iv // .A---f,AtzV9 czziisie ./,;.../ , - 71. .S. fr- , t79 - - ! : - ,, -,--- L,.. _.4 :,,,,,1 (..i• Pt fit",9 . - - — - - — - — -El — — — — --ci — .1-- . , 4' ,... ...„: ,... (.4_-? 7 .__.9 ,t. ,,,,---, 7-2-/ ,-./....44_,-,- /1( (1- " to sr- tr 9p -)-2 /(1 • 5 — — , , 374(2r ?ilvf /15-7 , . .aiv • 4;,..-..;,---2y . ,. -, _iee..._? a21, ., . 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SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �/ Not Applicable ❑ Name of License Holder : `✓ G //S-Li i`/ • S/ i.41/ License Number S /yG� /2 h C 4 f e'ra /`/A O /ay �2 / Address // Expiration Date Signature E� Telephone ti. 9., Registeio�`Home lmprovement.Coiitractor Not Applicable ❑ ✓ / �r�Yr /u.. /cj / /3 Company Name Registration Number /) /P4_ F < /k , 9;7 7 - 0 (97/2_ Address Expirati.Dh 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No ❑ EtZ4 tint .Ownei cfli1p>ian The_current_exemption.for `_`homeowners" was extended to include Owner-occupied Dwellint+ss 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 ofiand on which he /she resides or in:ends 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 referenceto 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 he 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 o amp on a r. t arc- a - an • t t2T[lnrg` . u w tts eneral -L;iws Annotated. Homeowner Signature _ 1 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: ._ w R _ . _ L :_..__. R'.__ _ .. s_.. .. __.__, Rear i ._ Building Height - Bldg. Square Footage , _W _. % 1 ---- 1 z ___. Open Space Footage (Lot area minus bldg & paved 1 parking) # of Parking Spaces — - •• -- -- --` Fill: I ; (volume & Location) ;_._ _. -- __. __.... _. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW e YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW G YES 0 IF YES: enter Book Pagel I and /or Document # w 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 0 Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO t° IF YES, describe size, type and location "� "D'. 'Area any proposed changes to or additions of signs intendedMTM Fproperty ? 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 IF YES, then a Northampton Storm Water Management Pemtit from the DPW is required. J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House 0 Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors C7 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [DI Other [pc Brief Descr tion of Proposed 7 r+r-c 7t 4c.E.,.1r j Work: / /.f// ,e,/...:49A .3� 5 c� g/6"6"--le-r" - f' it,/ 5/ z /1` ee i Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative - - -- Renovating unfinished basement x _Yes No Plans Attached Roll (Sheet; 641NeVf3`i and: O : r:. addition exis €rncj housing, complete the.followlncj: a. Use of building : One Family K., Two Family Other b. Number of rooms in each family unit: 3 Number of Bathrooms 2 4 c. Is there a garage attached ? / 6-3 j c/ x i3 ,5,4, -,, 7 3 2- Sk i d. Proposed Square footage of paw construction. y Dimensions /( )< .z-- e. Number of stories? z f. Method of heating? OA r ■/A Fireplaces or Woodstoves % Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i.-- Fig?.. t= i. Is construction within 100 ft. of wetlands? Yes / No. Is construction within 100 y -. floodplain Yes K' No j. Depth of basement or cellar floor below finished grade � i k. Will building conform to the Building and Zoning regulations? SC Yes No . I. Septic Tank < City Sewer Private well City water Supply K SECTION la:- OWNER AUTHORIZATION - TO BE COMPLETED WHEN , OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,, r r I, M ( 4 &i � f `. r , as Owner of the subject propert hereby authorize LA f-t> f 4. 2 /E z i , 4S(C( tq c n my ehalf, in all maters relative to work authorized by this building permit application. Sign tune of Ow r Date I, . c- // -/Z___ , ash /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. :I - C(/ e // 2 ,' —z ef /.i 5(6j` Print Name Signature of 0 , er /Agent % Date • Departmentyse only City of Northampton Status of Permit B uilding Department • , Curb;GUtlDnvevray tsermrt ° .... a 212 Main Street SeweriSept+c Aval►st?rllty y Room 100 WaterMlel1 Avadabtltty Northampton, MA 01060 Two ,Sts of Structttrel Plans. , \ -„ J • fi g ik y K �,' phone 413- 587 -1240 Fax 413 - 587 -1272 PlovlStte Plans Oth SpeciTy 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 / e.j,1 G DL69i✓1h Map Lot: Unit ` Zone Overlay District ©/C L Eh St: District . CB District SECTION 2<- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C Gv v®2) c t I Na e (Print) Current Mailing Address: Telephone Sign : turd 2.2 Authorized , Agent:/ �`%/w'd' /1-. 2 �E=-' 1 / G�J S (� G G� 0 �'Tj /2 i (�G E C i.<' /'� 4 e - z ij /Y Name nnt) Current Mailing Address: ° / ;/99 Cc � Signature ? Telephone SECTIO 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be C)fficial Use Only completed by permit applicant 1. Building t ei 9 f-0 (a) Building Permit Fee 2. Electrical 614 p (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 7 S Q 5. Fire Protection 3 0 6. Total (1 + 2 + 3 + 4 + 5) 3 �� L 0 Check Number This Section For Official se Orily Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of- Buildings' Date File # BP- 2011 -0445 APPLICANT /CONTACT PERSON JOHN ZIEMINSKI ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413) 247 -9014 PROPERTY LOCATION 109 WOODLAND DR MAP 35 PARCEL 292 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Y� p .�t?,, Fee Paid / j5 i� g Tvpeof Construction: FINISH 432 SQ FT BASEMENT FAMILY ROOM New Construction Sr A C e C.4 u( S r ry a C E a: E b A$ .3 Eb ado c►m 0 Non Structural interior renovations > Ler `' 1 U CT Ala fi : (,0 D TEC Ta t: MST 6( its 5 t. -E b Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 017889 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: L _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 Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay 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. r BP- 2011 -0445 GIS #:: COMMONWEALTH OF MASSACHUSETTS r 1oc ` CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0445 Project # JS- 2011- 000725 Est. Cost: $23000.00 Fee: $138.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq. ft.): 34325.28 Owner: ARMSTRONG KIPP S & PATRICIA S Zoning: SR(100) //WSP II Applicant: JOHN ZIEMINSKI AT: 109 WOODLAND DR Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247 -9014 Workers Compensation HATFIELDMA01038 ISSUED ON:11 /15/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: FINISH 432 SQ FT BASEMENT FAMILY ROOM - NOT TO BE SUED AS BEDRM OR SLEEPING AREA - CO DET MUST BE INSTALLED 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 11/15/2010 0:00:00 $138.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner