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32C-149 (21) V FES13 "� DEN RTHAM TON,'MAP NS 01 6O 52,6- __.i 2'4 _-_ _-_.g• - - 182 _- _.__- i_ 4.8 __-_'{ 25- 4'11 1 1- �.2'3�.--2'11._". --28 _-_. _ 64_-_- i- -3'2. _..___8'6_-- __ _ g'6. --2'5 2'3 � -� m I dc, JI I I i _ 179_...__-___ _ -- 263 -__ -_'�._-33 -_1-.- _ -.._ -12' h _52'6.__ Tt�MPT •�04 F ' o a� CfLZ -� Df 'Nart4ailtpfon B �XSSXCI�ttsrtl5 s DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building S��s Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIEDAVIT with a principal place of business/residence at: rpq (phone#) r 5.YC (street/city/staff-hip) do hereby , under the pains and penalties of perjury, that: ( am an employer providing the following worker's compensation coverage for my employ woricing on this job: (Insurance Co ) (Policy Number) (Expiration Daze) ( ) 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) (lnsurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach ad&tioml sheet if necessary to include irdbm rioa perudaing to all matutm) ( ) I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE-please be aware that while homeowners who employ pe om to do=i tc �suction or repair wodc on a dwelling of not morn than throe units is which the houaowu r resides or on the grounds appurteaaat thereto=not gcoer&4 oomidered to be employers under the worka,'s compecutim Act(OL152,m 1(5)),application by a homeowner for a liceme or permit may evidence the legal statue of an employer under the Workees,C enpematioa Ad - I understand dust a copy of this statement may be forwarded to the Depa-tm of In&ohisl Aeddm Office of Iawrwaa for the oovasge vaificzdoo and that failure to covango under section 25A of MGL 152 can lead to the WV03i -of criminal peaaltiea coasisting of a fine bf up 1 SI SOO.QO impaiso�of up to one year and civil penzWes in the form of a Stop Work Order sad a fine of 3100.00 a_ y against mo. For dq=tWWW use only c� permit Number G Map#____Lot# Si of Lt SECTION 8,eONST,ROCT ON SERVICES Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: � _�� (, License Number Acl r Expiration D to Sig ture Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTIQN'11J-,1NAR00V C©11►1PEN5ATION INSORANCE AFF11)"IT(M.G.L.c.152,§25C($)) Workers Compensation Insurance affidavit mW be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of building permit. igned Affidavit Attached Yes....... IV No...... ❑ 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 1 ON O al l' a e New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ Brief Description of Proposed Work: O C h � F Alteration of existing bedroom Yes No Adding new bedroom Yes i�°'d"r"-'' Ae-f S ►� 044 I Attached Narrative❑ Renovating unfinished basement Yes o Plans Attached Roll ❑ - Sheet❑ 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? 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 4WNEIR AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT co as Owner of the subject property hereby authorize to act on My behalf, in ail mawrs rela ive tow k authorize this buil ng permi application. Signature of Owner Date A014111,4 47 A �4 4-A as Owner/Authorized Agent hereby decl a haWtbe at ements and informs rif on t e ore oing application ale true and accurate, to the best of my knowledge and belief. igned der the pains ano penalties of perjury. Print Arne k Signature of OArm& t DA 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: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Ha=DON'T it/Variance/Finding ever been issued for/on the site? NO KNOW 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 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: �. x, DE C E mpton imn, rtment FEB reet 0 A 01060 WfA&U W11Jr $40 F x 413-587.1272 NORTHAMP70N, A 10 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SfT�INFQRMATION d e eif'� 1.1 Properly Address: ; )may■�fy r 'PAW (n( - f Ma T 4 xj -77777777, 77 F 4, gte �ti�� r� i s SECTION 2:.P W ORIZED AGENT i7 f �1H 2.1 Owner of Rec rd: LL The Hampshire Property ame(Pant) � Signature zZ J 2.2 Authorized gent: IL n — — t- - a e(Pri ) Current Mailing Address: ( �® zi �� Signature Telephone � rTIOI�I� �STIMATBD GaNSTRUCTION Cgs Item Estimated Cost(Dollars)to be Official Use Only completed bypermit applicant 1. Building (a) Building Permit Fee 2. Electrical 1 1000 (b) Estimated Total Cost of Construction from 6 3. Plumbing ^ Building Permit Fee e 4. Mechanical (HVAC) 5. Fire Protection 6. Total =G + 2 + 3 +4+ 5) f✓ Check Number This Sedtion For Official Use Only SuiIding Permit Number: Date Issued; Signature: Building ConriM!ss onerlinspector of Bu t.dings Date l^t; AV 4 � y ciw .l ¢ •• 4 ,+ vYY�lm Wool- a (0 �1 Y'� fi +� j, ie ry At TV �nyv ills OKA R,lot VIA all, ,r =rFtq x fi f � Y' y �rx� 3 7 � 1 b 285 PLEASANT ST-2L - SP-2001-0690 AL GIS#: COMMONW ALTH OF MASSACHUSETTS Man.:Black:32C- 149 CITJY OF NORTHAMPTON ,Lot: 00i Permit: Building . � Category:renovation BUILDING P � IT Permit# BP-2001-0690 Project# JS-2001-1262 Est.Cost:$20000.00 Fee:$100.00 PERMISSION IS HEREB Y GRANTED TO: Const.Class: Contractor., License: Use Group: THOMAS J KORYTOSKI 070047 Lot Size(sa.ft.): 10715.76 Owner: MCCARTHY PROPERTIES INC. Zoning: GB Applicant. MCCARTHY PROPERTIES INC. AT. 2$5 PLEASANT S T'- 2L Applicant Address: Phone: lAsurance: 64 LYMAN RD, NORTHAMPTONMA01060 ISSUED ON:2116101 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL APT 2L,REMOVE PLASTER,INSULATE,SHEETROCK, CABINETS,NEW BATH,KITCHEN UPDATE PLUMBING&ELECTRIC POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: 1916-71, , J?yy Rough: �'�,1'�0/ �}��House# Foundation: _ S x • t'°gnat. P.tr�741 &/ !v Rough Frame: Gas Fire De artmen �./ Fireplace/Chimney: Rough: Oil: Final: Smoke: Final:O K g^it• ©I THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc `' � ur: 9 Fee Type: Receipt No: �.''' Date Paid: Check No: Amount: Building 2/16/010:00:00 1189 $100.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo