32C-195 (3) Y
o�Ct1AMPJ0
a6 �:sarschttartta'
DEPARTMENT OF BUILDrNG INSPECTIONS I
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKE,R'S CONIPENSAUON INSURANCE A.TI'ITDAVTT
(licensee/permittec) -
with a principal place of business/residence at:
yU 0 , n cck-,Jt-. 0l0`l1 (phone#) Z/I
(str�etici ty/staieyri p)
do hereby certify, under the pains and penalties of perjury, that.
(rfam an employer providing the following worker's coinpensaticn coverage for my
employees working on this job:
l -q 6 o 3
(IasuxaAcc 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) (Irrsurancc Company/Policy Numbcr) (Expiration Date)
r,
(Name of Coutractor) (Insurance Company/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Fa-pimlion Date)
(Name of Contractor) Gnsutaace Company/Policy Number) (Expiration Date)
(aUaGh additional Slxei if nece txry to incluck inronlutioa patainin&to all vAl!reeton)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please lx awzrc that while hatroxucrs wbo claplay pazotn to do maiutcaan�-c,oous:n:c'.ioo or repair work on a dwalliag of
not ma c t1Ln tlrtro UL in%`ECf'the homco--r trsidcs or on L gv appurknant ttxrcto arc Dot Ecrxrally wnSiticrcd to be
ctttploycra unia the WueKzes ccmpasatioa Act(GLl52,s 1(5)),applica i"by a hots=%'.-r for a Uccme cc permit may cvidcnoc the
It-811 etatue of an omployer under dic Work.a'a Comp*mLtioa Act
I andastand thai x copy of this uatcma t ally bo forwardod to tbo Dcpcutnxo2 of i
L" vial Acard<-Ay Offioo of rriwnaw for the
oova-age vcrif catioo and flat failure to yxurc co%trngu UO&r scctioa 25A of hiOL 152 can lead to tl o imposition of c iminsl penalties
000sisting of a fmc of up to S1,500.00 and/or imprisoonxrat of up to one ycu and civil pcnalGi in d-Ic form of a Stop Work Ordc and a
fu-4 of 5100.00 a day against mc.
For.dcy�,Y all uio only
Permit Ntunber
Mapil Lot#
t � Stgurtnture of Liccnsc&permittcc e
SECTION 8 ;�CONSTRU.CTION SERVICES
8.1 Licensed Construction Supervisor- Not Applicable ❑
Name of License Holder : 'K �l�l 1j
License Number
PD. Bex ,-M - 4D Mw m .�4vJ n u.ee -3 - a y
Address Expiration Date
�as-� cu�nttin M A
Signature - I lep_hone
R'e�s''ereIm"°"ovemerit"Cone actor. w ;.. F
i Not Applicable ❑
X71 (cl z35
Cgmpany Name Registration Number
(21Z c) - - to - o14
Address Expiration Date
�6v 011 , Telephone`//3 5—,t?1—L 778
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...... ❑
',� -am, .
ome wner.ERxem ti 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 buildinp_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
SECTIONS DES�C�RIPTIONOF PROPOSED'WORK'JcheckaW applicable
)
i g.s
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing W_
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [[ ] Other [ ]
Brief Description of Proposed Work: xi I (,t,11 rzuji
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6alIfNho"'I"a"seandor additionao`existing Housing''corrplete'the=follcw:in :
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_
.1 777
SECTION 7a, OWNER-,AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 11 i am Zl')1 as Owner of the subject property
hereby authorize ` o-(-VeN ��\ , �b�- �` to act on
my behalf, in all matters relative to work authorized by this building permit application.
$ 4- 03
Signature of Owner Date
_ , as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing aloptilcation are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Nary/���y�
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
puking)
#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 #
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:
r
f Northampton o,
i ng Department p
1 Main Street
33 oom 100
�OONor ham ton, MA 01060 t
phone 87.1 40 Fax 413.587.1272 to
APPL 0 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-;SITE- NFORMATION
:This section t'oibe coinplet'i1b
1.1 Property Address: ,
1 a Y �
�oZ3- �a CJ VJI li Qms Map�� =4 Lot
��
Zone.= 4Dy District
Elm S't D i's tractCBSDisrict �
SECTION 2- OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\ l I I i am 81 i z n i a k 1� ss -h f�oad - .N'ion
Name(Print) Curre piing Ad ress:
- gaaS
Telephone
Signature
2.2 Authorized Agent:
Name(Pn t) 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 00 (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) C)fO,00 Check Number
.This Section For Official Use Only
Building_Permit°,Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings, Date
r
� ST BP-2004-0138
GIS#: COMMONWEALTH OF MASSACHUSETTS
k: C 195"; CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0138
Project# IS-2004-0214
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RCI ROOFING 126235
Lot Size(sq. ft.): 8102.16 Owner: BLIZNIAK WILLIAM&NANCY JANE
Zoning URC Applicant: RCI ROOFING
AT. 123 WILLIAMS ST
Applicant Address: Phone: Insurance:
P 0 BOX 309 (413) 527-4775 Workers
Compensation
EASTHAMPTONMA01027-0309 ISSUED ON:817103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 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
MW