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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Buil(hrig '
Northampton, Mass. 01060
wom ER,S COMTENSATION INSURANCE AFFIDAVIT
(li cense�cJpcnui ttec}
with a principal place of business/residence at:
y1dZ7 (phone#) L113 i%75
(street/ci tylstair/rip)
do hereby certify, under the pains and penalties of perjury, that.
I am an employer providing the following worker's compensation coverage for my
employees working on this job:
3�S `k l "`� Olk _ O �5 U
(Insu=& 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 workers compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparly/Poiicy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(Name of Contr-actor) (Insurance Company/Policy Numlxr) , (Expiration Date)
(saadt additioail t!xCt if iiccc luy to incluc4e aforZr s ioo peztaining to all croa:racton)
i
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work nryself.
NOTE:please lx awzrc thst while hocacowYxn who employ pa-;o=to do maintcuncc,cotis;n:dioa or repair work oo a dust-1119 of
not man than thrmo units in tiNhidt the bomc woe rich or oa the Ero�appuruus lhcrcio arc cwt Cc:xrally ooaridcrtd to be
cmploycn under the work ces ccxr pcsatiaa Acs(GL152„ss i(5)),application by a homoo-Ana for a 6—cc pcfaut may cvidmoc the
legal stabre of an amp Ioyoc under tiro Waik"s compom+tion Ad
I understand thxt a copy of this etatrnx auy be fouww-tlod to ttw De;xvturczf of Industrial Aoeidrnta'Of5oo of Insuc*neo for U-
covcrage vaificaiioa And that 541ure to s cure covaago mZcr sc, ioa 23A of btoL 152 can lead to tbo imposition of aiminsl pcoAlLes
oogsu=g of a fine of up to S 1,500.00 anNor unprisoaunr3 of tip to one y=and civil pcaaltics is the form of a Stop Work Order and a
find of 5100.00 a day against me
For dapuuzsat;51 wo oaty
" ''�
P Permit Number
C Lap"
Sipnature of Liccn c&Pemiittce e
SECT Ott 8 XONSTRUnCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: � `=`-z ��\ 9
License Number
C(U 410", V C1l�t ►1 �1/L_a L l .J _� O q
Address Expiration Date
Signature j� .r✓
B '- !/ Telephone
Not Applicable ❑edflolm �vemenf Contr
Company Name Registration Number
Address Expiration Date
q .��t l
d !v 6� to rti VIA-Q- Telephone ���3-j �,.y�!7S
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...... ❑
F .bw�',`�-x9'r'�
all: - - ometOwner Exempt><on
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 F(lition 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
SECT1O`Wf DESCRIPTION OF PROPOSED WORK check all'applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: IN G
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet❑
sa� IfNew hou e"�and�o`r��addition' o"existing:fousing, corriplete�the followin._g:
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=OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT O.R CONTRACTOR APPLIES FOR BUILDING PERMIT
i�',ayn !�L7-6Q _ as Owner of the subject property
hereby authorize x�1 C'L C_ N \ 3f V(S�t— C C�G�` �� to act on
my behalf, in all matters relative to work authorized by this building permit applicati .
8- 6 -63
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 7 r
Signature of Owner/Agent 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
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 Pern,it/Variance/Finding ever been issued for/on the site?
NO DON'T 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:
f Northampton
a �VJ i ng Department
Main Street
6 2003 oo m 100
� � Qt1G No ha ton, MA 01060
phon 87.1 40 Fax 413-587-1272 to
Qr HUILDiNG INSP�Q60
R�;titlr,
A TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT16N.1 -SITE JNFORMATION
jhis section;�to be com'pl'ef`d'[A% °c" 3 y
1.1 Property Address: �fh ,. �
Map �> Loot
pof � P •
P-1 �ttSCtr� - Zones Overlay DtstHE
^�
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\4'i t h am 23h zn i ak 1 a a C(0560alh Ed - .N`lS n
Name(Print) Current Mailing Add ss:58 4
Telephone a4
Signature
2.2 Authorized Agent:
Pc) 60x' 30,7 'c , Mcx. ota2-7
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 ROO�IY1 3 coloob (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) 3 boo OD Check Number
.This Section For Official Use Only
Building'Permit:Number: Date Issued:
Signature: '
Building'Commissioner/Inspector of Buildings Date
AS ;T BP-2004-0137
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0137
Project# JS-2004-0213
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft): 4268.88 Owner: BLIZNIAK NANCY J&WILLIAM J
Zoning: GB Applicant. RCI ROOFING
AT. 223 PLEASANT ST
Applicant Address: Phone: Insurance:
P O BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTON MAO 1027-0309 ISSUED ON:817103 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE FRONT PORTION OF 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• Receipt No: Date Paid: Check No: Amount:
Building 8/7/03 0:00:00 4343 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo