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29-337 (3) -Wk. OQ-��MpTO � a 9 g �Z 1QfD #(��11tIIll a 6 ,�Tasartciltartfa' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORIER'S COMPENSATION INSURANCE AFFIDAVIT Edj�)4 (license&permittee) , with a principal place of business/residence at: bAJ LC 016 )� (phone#) city/s &zip) do hereby certify, under the pains and penalties of pegury, that. I am an employer providing the following worker's compensation coverage for my employees working on this job: ) 000 W CgOnl& &?,� : -oI (Insurance Company) (Polity 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 Compatry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Connector) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insumace Company/Policy Number) (Expiration Date) (attach additional shod ifnoaensry to include infbmutioa pertaining to Lu ooaftndnn) ( ) 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 pecsom to do makde construction or repair work on a dwelling of not more than throe units it which the homeowter resides or m the grounds appurtenant therdo are tot gaxrany comider+ed to be employers under the worker's compensatioa Act application by a homeowner for a Gceasc or permit may a vidcxe the Iegat stanrs of an employer under the Workeet Compamaiion Act I understand that a oopy of this statement may be forwarded to the Depart=1A of In&t*ial Aoe&a&OtSoe of Iauuwoe for the coverage verification and that failure to sw=oowmgo uador section 25A of MOIL 152 can lead to the imposition of=roil pe:aakies oomistirg of a fine of up to$1,500.00 wNor izap isownc%t of up to one year and civil p=xl6cs in the form of a Stop Work Order sad a fim of s loo.00 a day against M For dgmtmrrtal use arty w Z Permit Number _Lot# ermittce Date SECTION 8-CONSTRUCTION SERVICES Licensed Construction Supervisor: �fj�y�, Not Applicable ❑ Name of License Holder: iA Wt`� �( �6 9©7 7 License Number 41 Addre Expon DFate Y 16 511 v 7 Sign. re Telephone � rW ... �: •..:�� `' Not Applicable ❑ A A1q , 3 - - ComQanv Name Registration Number IS I[Libr-&A • o Z Address Expirati n Date d Telephone SECT;QN 10-WORKERS'COMPENSATION:INSURANCE AFFIDAVIT,(M.G.L.c. 152,§2SC(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. ned Affidavit Attached Yes....... 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 k'alLapplicablej New House ❑ Addition ❑ Replacement Windows Alteration(s)15L Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ DemolitionD New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: ILFDAK of it?STS , cAyfTly bU t [ 51 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet D 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 SECTJR 7a-OWNER.AUTHORf ATIDiV -TO B�COMPL TED WHEN c1W # FiS AGENT,0R=Co RACTO.. APPI.iES F4 t SURLDINGPERMIT A'I�f N as Owner of the subject property , / jn n _ hereby authorize IR Y V` to act on .my behalf, in all matters relative to work authorized by this building per it applicatio . Sig ature Owner Date - If V` oTN as Owner/Authorized Agent hereby declare that the statements an informatio on the for g applicati n are true and accurate, to the best of my knowledge and belief. laigned under the pains and penalties of perjury. Print Name Signatur ne 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 Permit/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 # body v B. Does the site contain a broo k y 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: City of r mpton �z3 FEB 2 0 QMin rtment 212 Main ')treet LDFyT OF BUILDI IN PECTI M10 , on, A 01060 phone 413.5 7 1240 Fax 413-587.1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION This sects crrr ed b 1.1 Property Address: e y ,s 2Z uGrU; I v � � dl 0 r SECTION 2—PROPERTY.OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ame(Print) 4 Current Mailing Address: 4i S- Sgt- 3.� � Telephone Signature 2.2 Authorized Agent: M4- Name(P ) Current Mailing Address: 54n—a Telephone JON COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cast of Construction from 5 3. Plumbing Ouildin Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(I + 2 + 3 +.4+ 5) t}o . co Check,Number Th 4.Section For Official Use'Onl Buildinq.Permi#,lumber _ Date Issued: Signa�re; puifdlrtg Comrtti"ssiortierlirtspectur of Buildings Date File#BP-2001-0698 APPLICANT/CONTACT PERSON EDWARD GODLESKI ADDRESS/PHONE 18 LAUREL DR (413)584-9692 PROPERTY LOCATION 228 ACREBROOK DR MAP 29 PARCEL 337 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny Permit Filled out 14 1. _ Fee Paid L T_yueof Construction: REPAIR OF WALL STUDS JOISTS DRYWALL CAUSED BY TERMITES New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 069077 3 sets of Plans/Plot Plan THE,fi,MLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Co ion Permit from CB Architecture Committee Signature of wilding Officlal 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. 228 AGREBROOK DR BP-2001-0698 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-337 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0698 Project# JS-2001-1291 Est.Cost: $3900.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: EDWARD GODLESKI 069077 Lot Size(sq. ft.): 100 1 8.80 Owner., PURDY MARILYN A Zoning.URA Applicant: EDWARD GODLESKI AT. 228 ACREBROOK DR Applicant Address: Phone: Insurance: 18 LAUREL DR (413) 584-9692 Workers Compensation HADLEYMA01035 ISSUED ON.2/26/01 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR OF WALL STUDS,JOISTS,DRYWALL CAUSED BY TERMITES 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: Rough: House# Foundation: Final: Final: Rough Frame: 3� Zo a( Jale55e Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: 6 312, ZCel " l Final: Smoke: Final: 0J1 0�/ 7 L L l l J/ l THIS PERMIT MAY BE REVOKED BY THE CITY NORTHAMPTON UPON VIOLATIO. OF ANY OF ITS RULES AND REGULATIONS. � Certificate of Occupancy si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 2/26/010:00:00 3834 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo