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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenseeJpermittec)
with a principal place of business/residence at.
(phone#)
(s treei/ci ty/scatr/a p)
do hereby certify, under the pains and penalties of pcqury, that:
O I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Gnsu 3nce 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:
(Name of Contractor) (Insurance Company/Policy Number) (Expimtioa Date)
+r
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compazy/Policy Number) (Expiraton Date)
(Name of Contractor) (Insurance Company/Policy Number) (E-xpiration Date)
(anadr additional sleet if nccuv to ime}udc informiiion pertaining to all ocatractors)
t
O I am a sole proprietor and have no one worlsng for me.
I am a home owner performing all the work myself.
NOTE:please be aware that while hcmco -l)a3 who cmplay perl o to do m. i.,t�m i uc or repair worse on a dwelling of
not uroce than throo units in which the honmwucr resides or ca the grounds appurtenant thado arc not Ccncrally oonridacd to be
cmploycrs under the veovkc s c=V=54ca Act(GL152,ss 1(5)),application by a homeowms for a 6CCI23e oc permd may evidence the
ltgal aatun of an omployec under thn Workcet C;ompenu ion Act
I undaittnd th:t a copy of this sf stcmat msy bo forwarded to tbo DcQertmcat of Industrial Aoci&n&Offioo of Lff raoce for tba
coverage ve ificatioc and that failure to azure coverago under sociion 25A of MGL 152 can lead to the impasifion of aimall penalties
oomistiag of a fine'of up to S 1,500.00 andloe imprison of tip to one year and civil penalties in the form of n Stop Work Ord--and a
firm of 5100.00 a day agiiast mc.
For dcput m-w use only
Permit Number
IO_Lat#
Si of Lia nscrlPe
SECTION-8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� �,w�Y'.': Not Applicable ❑
9"R gisg��l�me ttiarouementContractor ,
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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
111W mo m pfi :n
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
j
SECTION S` DESCRIPTION OF PROPOSED WORK(check all applicable).
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:_ Sly x 1�l `
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
6a. if New tiotf"searTidoradd�tion aoezisting9 housing; completethe#ollowin
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 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:-OWN ER,:AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR°CONTRACTOR APPLIES FOR BUILDING;PERMIT
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, 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.
Print Name
Signature Ow gent 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
2 Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L R: m / D
Rear
Jv o
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 LIZ 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 t/ 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:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
1P 01*
City of Northampton
Building Department
ain Street
om 100 a f,
Norti pton, MA 01060 e .
i r)pl ope94 40 Fax 413.587.1272 P o �Stt�e
lig
I Q erSp et.
A l UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to�be'completed by office
1.1 Property Address: z: , t� � �
Map " t Uatt
4r
Zone rlay D�stnct
C�
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Michael �`!l(�nAi`e� .SZ/)i _ �trP �CJrJr /"f AA T �p -T- 7
Name(Print) Current Mailing Address:
—114 1:� 0ITS
TeIephon
Signature
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 ermit applicant
1. Building (a) Building Permit Fee
0
2. Electrical (b) Estimated Total Cost of
Construction,from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5) Check Number
..This Section For Official Use Only
Building Permit Number: lL Datelssued:
Signature:''
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0286
APPLICANT/CONTACT PERSON SZOSTAK MICHAEL P&MARGARET J
ADDRESS/PHONE 581 BURTS PIT RD (413)582-0152()
PROPERTY LOCATION 581 BURTS PIT RD
MAP 29 PARCEL 496 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid S=
Typeof Construction: ERECT 14 X 8 SHED
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
INFgKMATION 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
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commis
F�L /1/
- � u
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.
581 BURTS PIT RD BP-2003-0286
GIS##: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-496 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
CateQorv: BUILDING PERMIT
Permit# BP-2003-0286
Project# JS-2003-0493
Est.Cost: $2900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sa.ft.): 30012.84 Owner: SZOSTAK MICHAEL P&MARGARET J
Zoning: SR Applicant: SZOSTAK MICHAEL P & MARGARET J
,4T: 581 BURT PiT R1
Applicant Address: Phone: Insurance:
581 BURTS PIT RD (413) 582-0152 O
FLORENCEMA01062 ISSUED ON.9124102 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 14 X 8 S ED
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: LI f:� 5-P7- Q 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
r
Certificate of Occu anc si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/24/02 0:00:00 4148 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo